Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 7,
2020.

You asked the Plan to pay for the lumbar-sacral orthosis. You say that the service was medically necessary.
The Plan denied your request. The Plan says there is no evidence that an examination was performed by the
ordering physician.

The Plan follows Medicare rules. Medicare rules say that a spinal orthosis is covered when it is ordered for an
indication as specified in LCD L33790.

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 lumbar-sacral orthosis. Our reviewer
says that the service was not medically reasonable and necessary. Our physician reviewer found the
documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered
indications in this case, as there is insufficient documentation of a credible physical examination of the back.

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the
Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided September 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided July 14, 2020.

You asked the Plan to pay for the outpatient office visit. You say that you were told by the agent that this provider was in network. The Plan denied your request. The Plan says this claim cannot be reprocessed for payment until primary insurance (EOB) is received.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is secondary. As the secondary insurer, the Plan cannot be held responsible for the outpatient office visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient office visit provided July 14, 2020.
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 needs daily physician visits and special nursing care. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.

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 current acute care hospital with septic shock secondary to COVID-19 pneumonia requiring intubation and later tracheostomy and PEG placement. Recent notes state that the enrollee is becoming more alert, was able to be weaned to oral vasopressors, and is gradually tolerating CPAP mode. The enrollee appears to be improving and only requires short term additional acute care services, which can be safely completed at the current facility. He does not require services at the LTACH that are not already being provided at the current facility. Therefore, this request for LTACH services is not supported and will be considered 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CYRAMZA (J9308).

You asked the Plan to pre-approve CYRAMZA. You say that the service is medically necessary. The Plan
denied your request. The Plan says the clinical value and effectiveness of single agent CYRAMZA or when
combined with FOLFOX in the setting of cancer progression following prior treatment with FOLFIRI plus
Avastin have not been demonstrated in the peer-reviewed literature.

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 CYRAMZA. Our reviewer says that the
service is not medically necessary. Our physician reviewer found there is no documentation that CYRAMZA is
FDA-approved for the enrollee's diagnosis after treatment with FOLFIRI (folic acid, fluorouracil, and
irinotecan) and Avastin.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CYRAMZA have not been met. Specifically, the documentation does not
support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee
Therefore, we decided that the Plan does not have to pre-approve CYRAMZA (J9308).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and ambulance service provided on January 27, 2020.

You asked the Plan to pay for the ground mileage and ambulance service. You say that the enrollee was not under hospice care at the time of the ambulance trip. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and ambulance service provided on January 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for electroencephalogram (95882) and somatosensory testing (95927and 95938) provided on April 23, 2020.

You asked the Plan to pay for the electroencephalogram and somatosensory testing. You say that you would like reconsideration because you provide your own equipment and are not associated with the hospital. The Plan denied your request. The Plan says these services are not separately payable in a facility setting.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT codes 95822, 95927 and 95938 are not supported in the record. Specifically, the documentation submitted indicates that these services were rendered in a facility setting. Payment for these services is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the electroencephalogram and somatosensory testing have not been met. Therefore, we decided that the Plan does not have to pay for electroencephalogram (95882) and somatosensory testing (95927and 95938) provided on April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on September 17, 2019 by an out of network (OON) provider.

You asked the Plan to pay for home health services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

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 home health services provided on September 17, 2019 by an out of network (OON) provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for leg pain after a fall.
No fractures were found. The enrollee's medical conditions are stable.

There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation
needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation
program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the
enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 7, 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 procedure code 63042 is not supported.

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 63042 is laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar. 

We find that CPT code 63042 is not supported in the medical record. Specifically, there is no documentation that the procedure was performed bilaterally. 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 pay for the surgical services rendered on July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OPDIVO and YERVOY for the enrollee.

You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a recommended treatment.

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 the drugs. Our reviewer says that the
requested drugs are not medically reasonable or necessary. Our physician reviewer found the combination of
ipilimumab (YERVOY) and nivolumab (OPDIVO) is FDA approved for advanced hepatocellular carcinoma
after progression on sorafenib. There are no data on the efficacy of nivolumab alone or in combination with
ipilimumab in patients previously treated with an anti-PD-L1-targeted therapy such as atezolizumab. Therefore,
the combination in this enrollee previously treated with atezolizumab would not be 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 the drugs have not been met. Therefore, we decided that the Plan does not have
to pre-approve OPDIVO and YERVOY for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI scan of the arm joint.

You asked the Plan to waive the copayment for the MRI. You say that you disagree with the cost-share. The Plan denied your request. The Plan says the correct cost-share 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 $225 copayment for outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a $210.43 copayment for the MRI. The MRI falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for the MRI scan of the arm joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete upper denture (D5110) and the complete lower denture (D5120) provided on November 5, 2020.

You asked the Plan to pay more for the dental items. You say that the Evidence of Coverage says that the lower denture is covered with a $0 copayment. You say that you called twice before the procedure to verify that this information was correct. You also say that you were advised that it was correct both times. The Plan denied your request. The Plan says there is an annual maximum of $3,000. The Plan says that after the annual maximum is exhausted, any remaining charges are your responsibility. The Plan also says that the dentures were paid up to the annual maximum.

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 annual maximum has been exceeded. The record shows that the Plan paid $169 for dental services that you received on October 20, 2020, $975 for dental services that you received on November 3, 2020, and $1,856 for the dental services that you received on November 5, 2020. Additionally, the Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay more for the complete upper denture (D5110) and the complete lower denture (D5120) provided on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your care is not complex, and there's no need for a team of providers.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 physician reviewer found that you were admitted to the acute hospital for surgical repair of a hip fracture after a fall. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 

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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the vision care provided on September 30,
2020, by an in-network provider.

You asked the Plan to waive the copayment for the vision care. You say that this provider is on your list of
provider's you can use. The Plan denied your request. The Plan says the claim was processed accordingly with
your 2020 EOC 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).

Review of the file show that you received vision care services on September 30, 2020, from an in-network
provider. The exam was diagnostic and your 2020 EOC states that enrollees must pay a $40 copayment for
each in-network Medicare-covered exam to diagnose and treat diseases or conditions of the eye. Therefore, you
are asked to pay a $40 copayment for the vision care services. 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 vision care provided on September 30, 2020, by an in-network provider.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for chemotherapy for multiple myeloma. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frame (V2025) single vision lenses, sphere (V2100) provided November 15, 2020.

You asked the Plan to pay for the vision services. You say that please reconsider your claim. You were told you could get these glasses and file a claim for reimbursement. You would not have purchased if they would not cover. The Plan denied your request. The Plan says enrollee's must receive vision services from an in-network optical provider.

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 rendered by an in-network optical provider. 

We looked at the file and the Plan's rules. Enrollee's must receive vision services from an in-network optical provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for deluxe frame (V2025) single vision lenses, sphere (V2100) provided November 15, 2020.