Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for TMVR (33418) provided on September 19, 2019.
You asked the Plan to pay for the TMVR. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says TAVR procedures are only covered when they are reported with a modifier indicating participating in an approved clinical trial.
The Plan must follow Medicare rules. Medicare rules say that TMVR for MR claim lines in a clinical trial billed without modifier -Q0 shall be returned as unprocessable. We find that CPT code 33418 is not supported in the record. Specifically, the claim does not include the appropriate modifier to indicate the member's participation in an approved clinical trial. Based on this information, we decided that Medicare rules for coverage of the TMVR have not been met. Therefore, we decided that the Plan does not have to pay for TMVR (33418) provided on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Avastin infusion provided on July 23, 2019.You asked the Plan to pay for the Avastin infusion. You say that the provided Avastin was medically necessary.The Plan denied your request. The Plan says the provided Avastin was not medically necessary.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 pay for the Avastin infusion. Our reviewer says that the provided Avastin was not medically necessary. Our physician reviewer found the enrollee has had persistently and significantly elevated lactate dehydrogenase (LDH) raising concern for early pump thrombosis for which argatroban was administered, then warfarin therapy was resumed in combination with aspirin, and despite almost two years of Avastin use. The provider notes that the enrollee has required fewer blood transfusions since Avastin was started.At issue, the enrollee has been receiving Part B injectable treatment. The drug administered has been bevacizumab (Avastin) for indication: chronic blood loss anemia. Available records from 7/6/2019 note that Avastin has been provided to the enrollee per research protocol since August, 2017. Use of Avastin in the enrollee's setting as supported by his available record has been both off-label and investigational, and thus has not met Medicare coverage criteria.The enrollee's charted testimonial benefit is not supported by the necessity to resume warfarin therapy two year after starting Avastin. Relative to concerns for its long-term safety pertinent to the enrollee's case, per manufacturer Avastin carries a significant risk of gastrointestinal perforations and fistulae, as well as severe or fatal hemorrhage (including hemoptysis, GI bleeding, hematemesis, CNS hemorrhage, epistaxis, and vaginal bleeding) which have occurred upto 5-fold more frequently in patients on the drug under review.Finally, the provided literature citation, published internally by the clinic, regarding Avastin's experimental use in a limited series of hereditary hemorrhagic telangiectasia patients does not meet nor support the medical necessity or safety of the drug for the enrollee's indication.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 Avast ininfusion have not been met.Therefore, we decided that the Plan does not have to pay for the Avastin infusion provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe denosumab injection provided on September 12, 2019.You asked the Plan to waive the coinsurance forthe denosumab injection. You say that you cannot afford to pay this every month.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% coinsurance for each Medicare-covered Part B drug.You have been asked to pay $229.25, which is 20% of the allowed amount for the denosumab injection. The allowed amount is $1,146.24 (20% x $1,146.24 = $229.25). 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 forthe denosumab injection provided on September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that the requested Retacrit is medically necessary. The Plan denied your request. The Plan says the requested Retacrit is not medically necessary.
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 Retacrit. Our reviewer says that the requested Retacrit is not medically necessary. Our physician reviewer found the enrollee is diagnosed with malignant neoplasm of unspecified part of unspecified bronchus or lung. The requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. The enrollee has lung cancer of unclear stage but given RT and unclear if left lung lesion cancer likely stage III and not indicated for cancer being treated with curative intent. Likely anemia of chronic inflammation, renal function and anemia worse since recent admit for pneumonia and influenza. Also iron saturation is 11%. The requested use of Retacrit is not supported in any of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecore build up (D2950) for teeth # 6, 11, 12, and 13.You asked the Plan to pre-approve the core build up for teeth 6, 11, 12, and 13. You say that teeth # 6 and 11 have distal decay under the existing large composite core build up.The Plan denied your request. The Plan says core build up is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, core build up is not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecore build up (D2950) for teeth # 6, 11, 12, and 13.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Train-Of-Four testing (95999) provided June 18, 2019.
You asked the Plan to pay for the Train-Of-Four testing. You say that these services were medically necessary. The Plan denied your request. The Plan says the services at issue cannot be paid as a separate line item.
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 95999 is not supported in the medical record. Specifically, payment for the Train-Of-Four testing is included in the intraoperative Neuromonitoring codes already paid. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for Train-Of-Four testing (95999) provided June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network
provider on July 2, 2019.
You asked the Plan to pay for the services. You say that the provider told you they were in-network. The Plan
denied your request. The Plan says out-of-network services are not 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 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 services at issue in this appeal. 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 the medical services provided to you by an out-of-network provider on July 2,
2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory work provided on November 27, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that the blood work was necessary for your diagnosis and should be included with the physical you had on the same day. 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 $10 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood drawsor INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the laboratory work is considered a separate service.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 forthe laboratory work provided on November 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on November 19, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that you didn't think you would be charged. The Plan denied your request. The Plan says that you are responsible for the copay.
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 $265 copay for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $265 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip via ground ambulance 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 copay for the ambulance transport provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided to the enrollee on October 25, 2018 to November 1, 2018.
You asked the Plan to pay for this service. You say that the enrollee has prior authorization for this care under authorization number 06982298. You say that this claim is now being denied indicated a non-eligible provider status. The Plan denied your requested. The Plan stated your provider stated could not be verified.
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. A request for information to the health plan to confirm its denial as the information provided was contradictory to the records provided. This request was not responded to. In addition, portions of the case files (both submissions) were not legible. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we decided that the Plan has to pay for inpatient care provided to the enrollee on October 25, 2018 to November 1, 2018.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of an interlaminar/interspinous process stabilization/distraction device (22869).You asked the Plan to pre-approvethe insertion of an interlaminar/interspinous process stabilization/distraction device. You say that this is medically necessary.The Plan denied your request. The Plan says this is experimental.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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.Our physician reviewer found the device remains experimental. More research is needed before it can be considered medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of the insertion of an interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of an interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 13, 2019.You asked the Plan to pay forthe drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records for the date of service; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided on February 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chest x-ray to be provided at a tertiary facility.
You asked the Plan to pre-approve a chest x-ray to be provided at a tertiary facility. You say that the requested chest x-ray at a tertiary facility is medically necessary. The Plan denied your request. The Plan says the requested chest x-ray at a tertiary facility is 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 a chest x-ray to be provided at a tertiary facility. Our reviewer says that the requested chest x-ray at a tertiary facility is not medically necessary. Our physician reviewer found based on the documentation provided, there is no documentation of respiratory signs or symptoms. Therefore, there is no evidence to support that it is medically necessary to perform the requested chest x-ray at a tertiary facility, rather than at a non-tertiary facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a chest x-ray to be provided at a tertiary facility have not been met. Therefore, we decided that the Plan does not have to pre-approve a chest x-ray to be provided at a tertiary facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear purchased on October 22, 2019.You asked the Plan to pay for the eyewear. You say that you purchased the eyewear and received a discount because you had a coupon. You state that your benefits have not been exhausted because was the first claim during the current service year.The Plan denied your request. The Plan says you exhausted your benefit allowance.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.We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. The Plan paid reimbursed the $50 and your EOC clearly states, the Plan will provide reimbursement for up to $50 per calendar year. Therefore, you are responsible for the remainder of the cost.Therefore, we decided that the Plan does not have to pay for the eyewear purchased on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe cataract surgery provided on August 30, 2019.You asked the Plan to waive the copayment forthe cataract surgery. You say that you should not be responsible for this amount. 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 $350 copayment per visit. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $350 copayment for the cataract surgery.You have been asked to pay a $240.03 copayment for the cataract surgery. The cataract surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe cataract surgery provided on August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing services provided from June 21, 2019 through July 26, 2019 by a non-contracted provider.You asked the Plan to pay for hearing services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.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. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing services have not been met. The provider stating that your appointment was with one health agency on August 23, 2019 not with the other on June 21, 2019 -July 26, 2019.  For you to receive the hearing aid benefit through provider outlined on page 85 of your EOC document you will need to purchase hearing aids through the clinic that provider helped set your appointment for during the phone call with your spouse on August 21, 2019.  If you would like to utilize the benefits, provider recommends that you contact them at (844) 255-7144.Therefore, we decided that the Plan does not have to pay for hearing services provided from June 21,2019 through July 26, 2019 by a non-contracted provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortheoffice visit (99202), the hot or cold packs therapy (97010), the mechanical traction therapy (97012), the electrical stimulation (97032), and the therapeutic exercises (97110) provided on October 3, 2019.You asked the Plan to pay forthese services. You say that the services provided were medically necessary and should be reconsidered for payment.The Plan denied your request. The Plan says that theseservices are not a covered benefit under the enrollee's contractual policy.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the servicesat issue arenot manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe office visit (99202), the hot or cold packs therapy (97010), the mechanical traction therapy (97012), the electrical stimulation (97032), and the therapeutic exercises (97110) provided on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 14, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
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
laboratory services. 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 laboratory services provided on November 14, 2019.