Persius/hicric huggingface dataset:
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. You say that the enrollee needs to be discharged to rehab. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for coronary artery bypass grafting. His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from January 2, 2020, to February 5, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the services was not filed until February 5, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services provided from January 2, 2020, to February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for 1 additional unit of breathing circuits (A4618) provided
February 2, 2021.

You asked the Plan to pay for 1 additional unit of breathing circuits. You say that this request is medically
necessary. The Plan denied your request. The Plan says it is not appropriate to bill this service with a total of 2
units.

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 pay for 1 additional unit of breathing circuits. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found at issue in this case additional breathing circuit units are considered if there
is adequate documentation of medical necessity to support the reported units. Nothing in the provided medical
records supports that the additional unit of CPT code A4618 was 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 1 additional unit of breathing circuits have not been met. Therefore, we decided
that the Plan does not have to pay for 1 additional unit of breathing circuits (A4618) provided February 2,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia (01992) provided on October 21, 2020.

You asked the Plan to pay for anesthesia. You say that this is a payable code. The Plan denied your request.
The Plan says records have not been submitted to support this code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT code 01992 is not supported in the medical record. Specifically medical records have not been submitted for this service. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01992) provided on October 21, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 8, 2020 by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that prior authorization was not obtained because the visit was not pre-scheduled. You also say that the visit was medically reasonable and necessary.

The Plan denied your request. The Plan says the service was rendered by an OON provider. The Plan also says that prior authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care provided on October 8, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access for tooth #2 (D3331).

You asked the Plan to pre-approve treatment of root canal obstruction for tooth #2. You say that the services are necessary. The Plan denied your request. The Plan says the requested service 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 treatment of root canal obstruction; non-surgical access for tooth #2 (D3331).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for each outpatient non-radiological visit provided on August 14, 2020, and November 6, 2020.

You asked the Plan to waive the copayment for each outpatient non-radiological visit. You say that checking your device is covered. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 each outpatient diagnostic test and therapeutic services and supplies.

You have been asked to pay a $30 copayment for each outpatient non-radiological visit. The EOC confirms that $30 is the required copayment for this service. The total cost share amount is $60 ($30 x 2 visits = $60). Outpatient non-radiological visits fall 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 two (2) outpatient non-radiological visits for programming of a dual lead implantable defibrillator device provided on August 14, 2020, and November 6, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ground mileage (A0425) and non-emergent ambulance transport
(A0428) provided on September 28, 2020.

You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. You say that an
ambulance was called to transport you home because there was a concern for your safety. The Plan denied your
request. The Plan says that there was not an approved authorization for these services.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
For a service or item that is normally not covered, but could be covered under some conditions, the EOC alone
is not adequate notice of non-coverage. If no notice of non-coverage is given, the enrollee is held harmless. The
Plan follows these rules.

You were referred for the ground mileage and non-emergent ambulance transport by a contract provider. Nonemergency
ambulance transportation is an example of a service that is normally not covered but could be
covered under some conditions. The EOC is therefore, not adequate notice of non-coverage in this case. The
file does not show that the Plan provided notice that the ground mileage and non-emergent ambulance transport
would not be covered. Under Medicare rules, this means the ground mileage and non-emergent ambulance
transport is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the ground
mileage (A0425) and non-emergent ambulance transport (A0428) provided on September 28, 2020.

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alimta.

You asked the Plan to pre-approve Alimta. The Plan denied your request. The Plan says the drug regimen is not being prescribed for a medically accepted indication.

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. 

The file shows that Alimta to be used in combination with pembrolizumab was requested. 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 Alimta. Our physician reviewer found that the enrollee has right hilar mass non-small cell lung cancer. The requested use of the drug is not FDA-approved for the enrollee's diagnosis. Combination standards include Carboplatin. Also, there are no ALK or EGFR results in the case file. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Alimta have not been met. Therefore, we decided that the Plan does not have to pre-approve Alimta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of any indication to undergo an invasive procedure with potential to harm.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication in the records for this injection. The physical exam does not show radicular pain, and there is no tenderness over the facet joints. There is no limitation of range of motion delineated. There is no prior surgery, and no indication of neurogenic claudication. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by a tertiary
provider.

You asked the Plan to pre-approve services to be provided by a tertiary provider. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 services to be provided by a tertiary
provider. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found you have dermatochalasis and according to your primary
care provider requested to see the tertiary care provider. The records provided do not support the medical
necessity or reasonableness of the requested service as defined by Medicare rules. Your care needs can be
provided by a non-tertiary provider. Therefore, you do not meet criteria for the requested tertiary services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of services to be provided by a tertiary provider have not been met. Therefore, we
decided that the Plan does not have to pre-approve ophthalmology services to be provided by a tertiary
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Linzess.

You asked the Plan to pre-approve Linzess. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Linzess.

Benefits for Linzess 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the diagnostic radiological services
provided on November 12, 2020.

You asked the Plan to waive the deductible for the diagnostic radiological services. You say that you would
like the Plan to reconsider your request. The Plan denied your request. The Plan says you received diagnostic
radiology services on the date of service at issue in this appeal. The Plan says that the correct amount has
applied towards your deductible per your contract with the Plan.

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 $750 deductible that must be met before the Plan will pay their share
for Outpatient diagnostic tests.

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient
diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible that must be met before the Plan will pay their share for Outpatient diagnostic tests. This cost
sharing is a contractual obligation that had not been met at the time the diagnostic radiological services was
received on November 12, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the diagnostic radiological services provided on November 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered on October 21, 2020 to October 25, 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 services are not covered.

The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. 

We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on October 21, 2020 to October 25, 2020.

Benefits for these services 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided August 12, 2020.

You asked the Plan to pay for the emergency visit. You say that you have received a request for additional information concerning the attached dispute. In response you are providing the supporting documentation requested. The Plan denied your request. The Plan says the documents received does not meet CMS criteria for approval for code 99284. Provider was paid correctly for code 99282 - emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity.

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 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. 

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 emergency visit. Our reviewer says that the medical records do meet the criteria for the requested level of service. Our physician reviewer found the medical records provided do not include sufficient documentation to substantiate that the level of service defined in the description of 99284 was performed on August 12, 2020, therefore, this service cannot be verified. 

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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for LinQ Sacroiliac (SI) Joint Stabilization System provided
September 1, 2020.

You asked the Plan to pay for LinQ SI Joint Stabilization System. You say that this was medically necessary.
The Plan denied your request. The Plan says this procedure 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 pay for LinQ SI Joint Stabilization System. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this is an experimental and investigation procedure. Therefore, it is deemed
not medically reasonable or 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 LinQ SI Joint Stabilization System have not been met. Therefore, we decided
that the Plan does not have to pay for LinQ Sacroiliac (SI) Joint Stabilization System provided September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5261) purchased December 4, 2020 from the non-Plan hearing vendor.

You asked the Plan to pay for the hearing aids. You say that you did not know that this hearing vendor did not participate with the Plan. The Plan denied your request. The Plan says hearing aids purchased outside the Plan's hearing vendor network are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays up to $500 for hearing aids every three years when purchased through a Plan-participating hearing vendor. 

We looked at the file, and the Plan's rules. You purchased the hearing aid outside of the Plan's hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased December 4, 2020 from the non-Plan hearing vendor.