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

We decided that the Plan does not have to pre-approve Keytruda with addition of carboplatin/paclitaxel.
You asked the Plan to pre-approve the Keytruda with carboplatin/paclitaxel. You say that it is felt that adding these chemotherapy agents would have synergistic effect which might be successful. The Plan denied your request. The Plan says this regimen is only approved for first line treatment where no PD-1 inhibitor was tried yet. With progression on Keytruda, there is no support for continuation of Keytruda with or without other agents.
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 the Keytruda with carboplatin/paclitaxel. Our reviewer says that the requested chemotherapy regimen is not considered reasonable and necessary in this case. Our physician reviewer found this patient has progressed through first line therapy with pembrolizumab in multiple locations indicating a lack of response. Standard 2nd line therapy would not typically include continuation of a therapy on which a patient has progressed. Triplet therapy is not FDA approved for 2nd line therapy and is not a standard of care. Monotherapy was chosen as initial therapy because of her poor performance status and therefore with progression triplet therapy would be more toxic. The service is 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 the Keytruda with carboplatin/paclitaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda with addition of carboplatin/paclitaxel.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on July 29, 2019.
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis provided on July 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injectable drugs provided on January 16, 2018 billed with 18 units of code J3490.
You asked the Plan to pay for the billed units of injectable drugs. You say that this is correctly billed. The Plan denied your request. The Plan says it is not allowed to bill more than one unit of a NOC code since the narrative information is used for billing.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 18 units of CPT code J3490 are not supported in the medical record. The code J3490 does not have any associated units. We were not able to confirm the NDC code reported for this drug as being associated with J3490. As such, we cannot confirm that 18 units is the correct amount to report for the amount of drug dispensed. Therefore, we decided that the Plan does not have to pay for the injectable drugs provided on January 16, 2018 billed with 18 units of code J3490.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 13, 2019.
You asked the Plan to pay for the lab services. You say that this was medically necessary testing. The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.
The Plan must follow Medicare rules. Medicare rules say that all information must corroborate the documentation in the record and support that coverage criteria are met. In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested provider is not in the plan's network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services.
You asked the Plan to pre-approve the physician's services. You say that you would like to go to a neuro-psychologist because you believe your life is at risk due to stroke induced aliments. The Plan denied your request. The Plan says in most cases care you receive from an out-of-network provider will not be covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a surgical procedure on humerus or elbow (24999) performed on July 24, 2019.
You asked the Plan to pay for a surgical procedure on humerus or elbow. You say that an unlisted code was used because there is no procedure code for the service that was performed. The Plan denied your request. The Plan says this code is not listed as being covered in an ambulatory surgical center.
The Plan must follow Medicare rules. Medicare rules say that the complete lists of ASC covered surgical procedures and ASC covered ancillary services are available on the CMS Web site. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a surgical procedure on humerus or elbow have not been met. Specifically, the billed CPT code is not included on the list of covered ASC procedures on the CMS website. This procedure is not covered when performed in an ASC. Therefore, we decided that the Plan does not have to pay for a surgical procedure on humerus or elbow (24999) performed on July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided August 6, 2019.
You asked the Plan to pay for the orthoses. You say that the records provided will show proof of medical necessity The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided August 6, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that because of medical conditions the enrollee needs orthotics to walk normally. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve batteries for your CPAP machine.
You asked the Plan to pre-approve the batteries for your CPAP machine. You say that where you live suffers from a lot of electrical power interruptions. You say that this means your apnea machine cannot be used as often as needed without batteries. You say that you need to use this machine both day and night. The Plan denied your request. The Plan says the item being requested is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve batteries for your CPAP machine.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for continued skilled nursing facility (SNF) services after June 24, 2019.
You asked the Plan to pay for SNF care. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says that medical necessity cannot be established for continued SNF level of coverage.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before June 24, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pay for continued skilled nursing facility (SNF) services after June 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the a transcutaneous electrical nerve stimulation (TENS) device to be provided by out of network provider..
You asked the Plan to pre-approve a TENS device with an out of network provider. You say that your current TENS device is broken and you want the same model from the provider. The Plan denied your request. The Plan says a different provider is the in-network provider
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the a transcutaneous electrical nerve stimulation (TENS) device to be provided by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on August 27, 2019.
You asked the Plan to waive the copayment for the laryngoscopy. You say that your policy says that you would be responsible for a $45 copayment. You say that you should not be responsible for the additional copayment. 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 a $295 copayment for surgery services at an in-network outpatient hospital. You have been asked to pay $158.88, which is less than the standard $295 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the copayment is for the laryngoscopy services provided by the hospital. 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 laryngoscopy provided on August 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auryxia tab 210mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication does not fall under the Part B benefits.
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 Auryxia tab 210mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent 300mg/2ml syringe for the enrollee.
You asked the Plan to pre-approve the syringe. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy with the Plan.
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 Dupixent 300mg/2ml syringe for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on August 23, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you were not informed there would be liability for a follow up. You say that you should not have to pay for an unnecessary test. 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 a $50 copayment for each Medicare-covered test. You have been asked to pay a $50 copayment for the ultrasound. The ultrasound 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 ultrasound provided on August 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic connector to 2 power options (E2311).
You asked the Plan to pre-approve the electronic connector to 2 power options. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested upgraded electronics 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 the electronic connector to 2 power options. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's strength on the left upper extremity and ability to self-feed is sufficient to control the power options with their separate switches already included with the approval of these power options 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 electronic connector to 2 power options have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic connector to 2 power options (E2311).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent Injection 300/2ml for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 Dupixent Injection 300/2ml for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray (70419) provided on September 5, 2019.
You asked the Plan to pay for an x-ray. You say that this was denied in error. The Plan denied your request. The Plan says that payment this service is included in CPT code 74022.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan states that this service denied due to being a column II code to 74022. However, the Plan did not submit documentation to show that code 74022 was billed on this date of service. The claims included in the case file show that codes 74019 and 70415 were billed. These codes do not have a column I/column II relationship. The Plan's denial cannot be substantiated with the submitted documentation. Therefore, we decided that the Plan has to pay for an x-ray (70419) provided on September 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 28, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that this should not be paid since the correct imaging was not completed. 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 a $150 copayment for each Medicare-covered advanced radiology service. You have been asked to pay $126.89, which is less than the standard $150 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the CT scan was performed. 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 CT scan provided on October 28, 2019.