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

We decided that the Plan does not have to pre-approve stereotactic radiation therapy for the enrollee.
You asked the Plan to pre-approve the requested services. You say that the enrollee's medical condition justifies aggressive treatment. The Plan denied your request. The Plan says stereotactic body radiation therapy would be acceptable for liver metastasis that was the entire tumor burden and enclosed within the treatment field; the enrollee only had one lesion treated.
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 requested services. Our physician reviewer found that stereotactic body radiation therapy (SBRT) for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the enrollee's performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks. The recent SABR-COMET study also supports treatment of oligometastases with SBRT. However, this enrollee is only being offered SBRT to the liver metastases. It is unclear from the records if the enrollee had had many liver lesions, that responded to chemotherapy, and now has 2 liver lesions. This would be considered oligoprogression. SBRT for oligoprogression is being studied, but not considered a standard of care approach. Therefore the requested services are not considered medically reasonable and necessary for the 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic radiation therapy for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.You asked the Planto pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says this is not medically necessary, as the documentation does not support disease progression beyond the current therapy.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no evidence to support that the requested drug is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 26, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 23, 2019 through November 30, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because, per CMS CPT code S9328 is a valid code. The Plan denied your request. The Plan says CPT code S9328 has a status indicator of I and is not valid for Medicare purposes.
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 CPT code S9328 is not supported in the record. Specifically, the the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on November 23, 2019 through November 30, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from August 28, 2019 through August 30, 2019, the ER visit provided on September 19, 2019 and physical therapy provided from September 3, 2019 through September 19, 2019. You asked the Plan to waive the copayment for physical therapy and the ER visit.. You say that you never saw a doctor. You say that the charges are absurd. The Plan denied your request. The Plan says the copayments 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 $40 copayment for physical therapy at an in-network outpatient hospital and a $120 copayment for emergency services in an emergency room. You have been asked to pay a total of $360 for physical therapy and the ER visit. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The ER visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for physical therapy provided from August 28, 2019 through August 30, 2019, the ER visit provided on September 19, 2019 and physical therapy from September 3, 2019 through September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing services provided to the enrollee on March 7, 2019.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says if there is no documentation the evaluation/testing was in relation to specific symptoms or treatment, the test is considered a screening service and denied as not covered under Medicare.
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 the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. Z codes have been used for billing. Paperwork was not signed for five months. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 services have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing services provided to the enrollee on March 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the prostatectomy provided from December 4, 2019 through December 5, 2019.
You asked the Plan to waive the copayment for the prostatectomy. You say that this should be processed as an inpatient hospital stay. You say that the claim should be reprocessed to a $250 inpatient 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 $325 copayment for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $325 copayment for the prostatectomy. The prostatectomy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that this was an outpatient procedure. 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 prostatectomy provided from December 4, 2019 through December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a specialist visit provided by an out-of-network provider on October 16, 2019.
You asked the Plan to waive the coinsurance for a specialist visit. You say that you disagree with the out-of-network charges. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for out-of-network physician/practitioner services, including doctor's office visits. You had a specialist visit on October 16, 2019 from an out-of-network provider. The allowed amount is $145.04 and 50% of that is $72.52. You have been asked to pay the total coinsurance amount of $72.52 for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a specialist visit provided by an out-of-network provider on October 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy services provided from December 9, 2019 to December 16, 2019.You asked the Plan to pay forhome infusion therapy services. You say that the Centers for Medicare and Medicaid Services (CMS) website lists this as a valid code.The Plan denied your request. The Plan says the denial of payment for these services is correct, because the billed code is not valid for Medicare purposes and is not payable.The Plan must follow Medicare rules. Medicare rules say that procedure code S9328 is not valid for Medicare purposes and is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home infusion therapy services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy services provided from December 9, 2019 to December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on November 8, 2019.
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you were informed the injection was covered with no mention of a copayment. You say that the amount should be adjusted or waived. The Plan denied your request. The Plan says the coinsurance 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 20% of the Medicare-allowed amount for Medicare Part B-covered drugs.
You have been asked to pay $346.13, which is less than the standard 20% coinsurance for the denosumab injection. The denosumab injection falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for continuous glucose monitor supply allowance
You asked the Plan to pay for continuous glucose monitor supply allowance (K0553). You say that the supplies were medically necessary. The Plan denied your request. The Plan says that there is no written order for the supplies.
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. The Plan did not provide any previous billing information or CGM approval documentation. Therefore, we decided that the Plan has to pay for continuous glucose monitor supply allowance
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on October
16, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that your claim was denied and
there are no in-network providers within 100 miles of your address. The Plan denied your request. The Plan
says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for each in- and out-of-network Medicare-covered one-way trip via ground ambulance.
You have been asked to pay a $250 copayment for the ambulance ride. The ambulance ride falls within the
"Ambulance services" benefit category. This means that you have been asked to pay the correct amount based
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the
ambulance ride provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 19, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved
for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says
that there are in-network providers available.
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 has network providers
available who can provide 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 an office visit provided on September 19, 2019 by
an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you had fallen in your home and could not get up. You say that there was no one around who was able to assist you and so your wife called emergency services. The paramedics arrived and assisted you up. You had minimal injures that did not require a trip to the hospital and after the paramedics took your vitals, they left and you went about your day. You say that it would have cost the Plan far more if you had been transported and that you believe that the situation should be covered by the Plan. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 29, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found theenrollee was admitted to an acute hospital on 1/20/20 with a left middle cerebral artery (MCA) cerebrovascular accident (CVA). Her deficits are aphasia and right hemiparesis. She was discharged to an IRF on 1/24/20 where she stayed till 2/19/20 and went home with home health services. She was re-hospitalized from 2/20 till 2/24/20 and discharged to a SNF. She is receiving therapy in the skilled nursing facility (SNF) making good progress. The enrollee is working with speech therapy, physical therapy, occupational therapy and an IRF admission was initiated.Based on review of available records, the enrollee does not meet criteria for coverage for an IRF admission. The enrollee is generally medically stable after having a stroke 3 months ago and undergone acute, home health and SNF rehab. She had no recent neurological or Orthopedic events and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehab physician three times per week or need for acute rehab nursing care. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. The requested admission to an IRF is 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 14, 2019 through October 21, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because, per CMS, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status code of I and is not valid for Medicare purposes.
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 CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 14, 2019 through October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 13,
2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you want to make sure the
charges are correct. The Plan denied your request. The Plan says the claims were processed correctly and you
are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for each specialist visit.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your
request. The Plan says the use of Keytruda is not supported.
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 Keytruda. Our reviewer says that
Keytruda is not medically necessary in this case. Our physician reviewer found the FDA and compendium
supported use of first line Keytruda for non-small cell lung cancer (NSCLC) if the PDL1 score is at least 1%
and if the tumor is negative for epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase
(ALK) mutations. Because the submitted documentation does not contain EGFR test results, the requested use
cannot be determined to be 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 Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda.