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

We decided that the Plan has to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Opdivo. Our reviewer says that the medication is medically necessary. Our physician reviewer found continuation of therapy is important as disease seems to be stable. The use of ongoing nivolumab is reasonable and 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 Opdivo have been met. Therefore, we decided that the Plan has to pre-approve Opdivo.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 12, 2021 by a non-participating provider.
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 were rendered by a non-participating provider without 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 referring provider is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 12, 2021 by a non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 19, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the records indicate an inability to tolerate the required amount of therapy services in an
IRF.
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 reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for a femur fracture and had revision of knee arthroplasty. Medical problems are stable. There are
no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the medical record supports a need for physical and/or occupational therapy, there is no documented
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care.
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99203) electrical stimulation (G0283) provided January 8, 2021.

You asked the Plan to pay for the chiropractic services. You say that .have had previous visits with this provider in which you had the same procedures done and no denials The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.

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 service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99203) electrical stimulation (G0283) provided January 8, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided on October 4, 2020.
You asked the Plan to pay for the emergency room services. You say that the medical records provided support the services in dispute. The Plan denied your request. The Plan says the enrollee has effective primary insurance with another carrier, and their own plan is secondary. The Plan says that it is the provider's responsibility to bill the primary group health plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the emergency room services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for emergency room services provided on October 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power-operated vehicle (K0800) purchased January 5, 2021, from a provider not certified with Medicare.
You asked the Plan to pay for the power-operated vehicle. You say that you were unable to find a provider certified with Medicare. The Plan denied your request. The Plan says the provider must be certified with Medicare in order to receive payment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the power-operated vehicle (K0800) purchased January 5, 2021, from a provider not certified with Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four 2D oral/facial photographic images and oral hygiene instructions provided on February 22, 2021.
You asked the Plan to pay for the 2D oral/facial photographic images and oral hygiene instructions. You say that you were not fully informed of your dental benefits before this visit. You also say that you believe client approval should be needed if these services are not covered except for in the case of an emergency. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits.
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 pay for the four 2D oral/facial photographic images and oral hygiene instructions provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed and powered pressure-reducing air mattress.

You asked the Plan to pre-approve a semi-electric hospital bed and powered pressure-reducing air mattress. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 

2. Requires attachments which can only be attached to a hospital bed; AND 

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 semi-electric hospital bed and powered pressure-reducing air mattress. Our reviewer says that the items are not medically necessary. Our physician reviewer found the requested items exceed your medical need as the documentation does not reveal pressure ulcers located on the trunk or pelvis or a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis. 

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 semi-electric hospital bed and powered pressure-reducing air mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed and powered pressure-reducing air mattress.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carbamazepine.
You asked the Plan to pre-approve Carbamazepine. 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 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 Carbamazepine.
Benefits for Carbamazepine 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a thoracic lumbar-sacral orthosis (L0464) provided on March 30, 2021.

You asked the Plan to waive the coinsurance for a thoracic lumbar-sacral orthosis. You say that you had a back injury, and the provider issued this item, and it is not working. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for DME and related supplies.

You have been asked to pay a 20% coinsurance for a thoracic lumbar-sacral orthosis. The allowed amount of the claim is $1,456.35, resulting in a coinsurance obligation of $291.27. The EOC confirms 20% is the required coinsurance for this service. A thoracic lumbar-sacral orthosis falls within the DME and related 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 coinsurance for a thoracic lumbar-sacral orthosis (L0464) provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for SNF care provided on October 9, 2020, to October 31, 2020.

You asked the Plan to waive the copayment for SNF care. You say that you do believe you should have to pay this bill. 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 $0 copayment per day, for days 1-20 for SNF care. Your contract with the Plan also clearly says that you must pay a $178 copayment per day, for days 21-100 for SNF care.

You have been asked to pay a $178 copayment per day for SNF care. The records show that you were charged a $0 copayment for days 1-20. The records also show that you were charged for twenty-three (23) additional days at $178 per day, Your total cost share is $4,094 ($178 x 23 days = $4,094). The EOC confirms that $178 is the correct copayment for this 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 for skilled nursing facility (SNF) care provided on October 9, 2020, to October 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing panel provided on September 16, 2020.
You asked the Plan to pay for the comprehensive pharmacogenomic panel. You say that this testing is medically necessary and should be reimbursed. The Plan denied your request. The Plan says he clinical value and effectiveness of comprehensive pharmacogenetic testing have not been demonstrated in tthe peer-reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered when ordering by a provider who is treating the enrollee for a specific medical condition and when the results will be used to manage this condition. There were no records from the ordering provider submitted. It is not possible to determine what medical
condition is being treated or that the results of this extensive panel are to be used to manage the enrollee's condition. Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing panel provided on September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional irrigation trays (HCPCS A4320).

You asked the Plan to pre-approve the additional trays. You say that this is medically necessary. The Plan denied your request. The Plan says this 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 the additional trays. Our reviewer says that the requested additional trays are not considered medically reasonable and necessary in this case. Our physician reviewer found you have a suprapubic Foley catheter which is chronic and changed once monthly by a home health care nurse. A request was made for 181 irrigation trays over 12 months, of which 12 were approved. There was no documentation supporting a need for more than monthly irrigation. Therefore, the remaining request for the additional 169 irrigation trays will be considered not medically necessary and not meeting criteria based on the provided documentation. 

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 additional trays have not been met. Therefore, we decided that the Plan does not have to pre-approve additional irrigation trays (HCPCS A4320).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgical procedure for repair of a wound and precancerous growth (17000, 13132, G8918, G8907) provided on September 4, 2020, by an out of network (OON) provider.

You asked the Plan to pay for an outpatient surgical procedure. You say that the Plan is a Medicare replacement plan where enrollees should be able to go to any provider that they choose. The Plan denied your request. The Plan says that the provider at issue is not contracted with the Plan for medical services, there was no authorization on file, no referring provider, and no misinformation given by the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 outpatient surgical procedure for repair of a wound and precancerous growth (17000, 13132, G8918, G8907) provided on September 4, 2020, by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342), and gingival irrigation (D4921) provided on February 4, 2021.
You asked the Plan to pay for periodontal scaling and root planing, and gingival irrigation. You say that the services should be covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 pay for periodontal scaling and root planing (D4342), and gingival irrigation (D4921) provided on February 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing provided on October 6, 2020.
You asked the Plan to pay for the pharmacogenomic testing. You say that this is medically necessary testing that must be covered. The Plan denied your request. The Plan says this claim was not billed with an appropriate POS code.
The Plan must follow Medicare rules. Medicare rules say that the POS code reported for lab claims must be where the sample was taken. POS code 81 is used when the lab takes the sample directly. The documentation does not support that the lab took this sample directly, meaning that POS code 81 is not supported. The sample was not received by the lab until October 23, 2020, several weeks after the sample was taken. Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenomic testing provided on October 6, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 25 to January 26, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the care at issue was a medical necessity for you. The Plan denied your request. The Plan says rules for payment have not been met because inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record did not show that, at the time of inpatient admission, the admitting physician reasonably expected that your necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on January 25 to January 26, 2021.