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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is status post L1-3 laminectomy, T12-L3 posterior spinal fusion, and L2 fracture stabilization. The enrollee required minimal/moderate assistance for transfers and activities of daily living. The documentation does not support that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. The enrollee's ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional therapy visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says therapy services are reviewed every four weeks to determine if the treatment is
improving symptoms/condition.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 visits. Our reviewer says that skilled
services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition.
Our physician reviewer found based on the records provided 18 visits of physical therapy are not indicated in
this case. The plan states that therapy services are reviewed every four weeks to determine if the treatment is
improving the symptoms and 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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve additional therapy visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a follow-up vascular surgery consultation with a contracted tertiary provider. You asked the Plan to pre-approve the consultation. The Plan denied your request. The Plan says that the requested care can be provided by a non-tertiary provider. The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 consultation. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a complex history with severe peripheral vascular disease, deep venous thrombosis and pulmonary embolism, a hypercoagulable state, status post venous thrombectomy and IVC filter placement, complete occlusion of the right common iliac and external iliac arteries, focal narrowing of the left external iliac artery, occlusion of the left popliteal artery. He also has severe coronary artery disease for which coronary artery bypass was recommended. There is medical record documentation from another vascular provider
documenting that he clearly requires tertiary care. According to the enrollee, he has been unable to see providers offered by the plan, as those providers felt that he requires tertiary care. 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 consultation have been met. Therefore, we decided that the Plan has to pre-approve a follow-up vascular surgery consultation with a contracted tertiary provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the cost sharing amount for the oral exam (D0120) and
prophylaxis (D1110) provided on February 13, 2020 by an out of network provider.
You asked the Plan to reimburse the cost sharing amount for the dental services. You say that documentation
that you received stated that you would be reimbursed in full for out of network dental services. The Plan
denied your request. The Plan says the dental services processed correctly. The Plan also says there is an 80%
coinsurance for dental services that you receive out of network.
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 dental services you received have
an applicable 80% coinsurance when you receive them out of network. This is a contractual obligation you
agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to
reimburse the cost sharing amount for the oral exam (D0120) and prophylaxis (D1110) provided on February
13, 2020 by an out of network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT code 01936 provided on October 17, 2019.
You asked the Plan to pay for CPT code 01936. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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 case file does not contain evidence that CPT code 01936 cannot be paid as it was billed, according to Medicare rules. The file does not contain a copy of a claim that contains both CPT codes 72275 and 01936 billed together on the same claim. It cannot be verified that payment for CPT code 01936 is bundled with another procedure that was billed on the same date of service. Therefore, we decided that the Plan has to pay for CPT code 01936 provided on October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from December 4, 2019 to December 19, 2019. You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you feel that you should not have had the hospital stay in the first place. 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 $285 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from December 4, 2019 to December 19, 2019. Therefore, you are responsible to pay a $285 copayment for days 1-5 (December 4, 2019 to December 8, 2019). $285 (copayment) x 5 (inpatient days) = $1,425. You have been asked to pay the total copayment amount of $1,425 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from December 4, 2019 to December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Moderate sedation services (99153) provided April 5, 2019.
You asked the Plan to pay for the Moderate sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not correctly billed.
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 99153 is not supported in the medical record. Specifically, this service cannot be billed as a separate line item. Based on this information, we decided that Medicare rules for coverage of the Moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for Moderate sedation services (99153) provided April 5, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the clinic visit provided on October 7, 2019.

You asked the Plan to waive the copayment for the clinic visit. You say that you believe you should only be charged a $20 copayment because you were not seen at a hospital. 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 $100 copayment for per visit. 

You have been asked to pay a $100 copayment for the clinic visit. The clinic visit falls within the "Outpatient hospital services" benefit category. The record shows you were billed by the outpatient 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 clinic visit provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (G0500, 99153) provided on November 1, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code G0500 is "Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)". The CPT Code Manual Definition of code 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedationsupports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primaryservice)".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 use of codes G0500 and 99153 is not supported by the records provided. Our physician reviewer found that there is no documentation that an independent observer was present to assist in the monitoring of the patient's level of consciousness. Therefore, the documentation does not support the billing of G0500. Additionally, there is no evidence that the physician himself provided additional sedation services beyond the initial induction/15 minutes. Therefore, the documentation does not support the billing of 99153.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 forthe services (G0500, 99153) provided on November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bitewings, prophylaxis, and periodic oral evaluation provided on February 15, 2018.You asked the Plan to pay forthe bitewings, prophylaxis, and periodic oral evaluation. You say that you did not know that you had any dental coverage.The Plan denied your request. The Plan says the claim was not submitted in a timely manner. The Plan also says that claims need to be submitted within one year of the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the bitewings, prophylaxis, and periodic oral evaluation was not filed until January 10, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe bitewings, prophylaxis,and periodic oral evaluation provided on February 15, 2018
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe chemotherapy services provided from January 2, 2019 to January 23, 2019.You asked the Plan to waive the coinsurance forthe chemotherapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received chemotherapy services on the dates of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.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 5% coinsurance for Medicare PartB prescription drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received chemotherapy services from January 2, 2019 to January 23, 2019. You have been asked to pay a 5% coinsurance for the chemotherapy services, totaling $867.10. The chemotherapy services fall 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 chemotherapy services provided from January 2, 2019 to January 23, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Duet transport chair rollator or the transport provided on September 18, 2019.You asked the Plan to pay forDuet transport chair rollator and transport. You say that you were advised not to move the enrollee yourself and the prescribed walker was cheap. The Plan denied your request. The Plan says you obtained durable medical equipment and a transport fromproviders who donot participate with Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The rules saythat Medicare does not pay forvan transport services. Payment cannot be made for the rollatorpurchased from thisprovider because the provider is not a medical provider and not enrolled in Medicare.Medicare does not pay for van transport services. Therefore, we decided that the Plan does not have to pay forthe Duet transport chair rollator purchased orthe transport provided on September 18, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe emergency room visits provided on November 14, 2019 and November 18, 2019.You asked the Plan to waive the copayments forthe emergency room visits. You say that you should not be responsible for the copayments. 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 $100 copayment for each in-network Medicare-covered emergency room visit. You have been asked to pay a $100 copayment for each of the emergency room visits. The emergency room visits falls within the "Emergency care" benefitcategory. 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 copayments foremergency room visits provided on November 14, 2019 and November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to wave the copayment forinpatient hospital services provided September 15, 2019 to September 24, 2019.You asked the Plan to wave the copayment forthe inpatient hospital services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing was applied.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 per day for days 1-5 for Inpatient Care. You have been asked to pay a $295 copayment per day for days 1-5 for the inpatient hospital services. The in-network out-of-pocket maximum of $6,700 was not met at the time services were rendered. 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 wave the copayment forinpatient hospital services provided September 15, 2019 to September 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dual-energy X-ray absorptiometry services provided on June 20, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe dual-energy X-ray absorptiometry services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 forthe dual-energy X-ray absorptiometry services provided on June 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the nursing home is responsible to obtain prior authorization. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.
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 the medical services provided on January 3, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNivolumab.You asked the Plan topre-approveNivolumab. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug 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 Nivolumab. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has hepatocellular carcinoma (HCC). The documentation supports that this is being requested to be given as first line treatment. Nivolumab is not FDA approved for first line-treatment of HCC. The NCCN compendium supports the use as first line single agent treatment for enrollees ineligible for tyrosine kinase inhibitors (TKIs)or other anti-angiogenic agents. The submitted documentation does not indicate the enrollee is not a candidate for TKIs or anti-angiogenic agents. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nivolumab have not been met.Therefore, we decided that the Plan does not have to pre-approveNivolumab.