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

We decided that the Plan does not have to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. The Plan denied your request. The Plan says the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules, and is not covered based on available information.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Rituxan. Our reviewer says that Rituxan (J9312) is not medically reasonable and necessary for the enrollee. Our physician reviewer found Rituximab is not FDA-approved for use in Susac syndrome. Our reviewer found that the use of Rituxan in Susac Syndrome is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer also found that the compendia is/are silent on the use of Rituximab in Susac Syndrome. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venclexta 100mg tablet for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.

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 Venclexta 100mg tablet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for adhesive strips (K0554) provided November 24, 2020.

You asked the Plan to waive the coinsurance for the adhesive strips. You say that you should not have to pay for the adhesive strips because they were not the correct size for your monitor. The Plan denied your request. The Plan says the claim was processed and the correct cost share was applied per the Evidence of Coverage.

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 durable medical equipment. 

You have been asked to pay $49.12 for the adhesive strips. The adhesive strips fall within the Durable medical equipment (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 adhesive strips (K0554) provided November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 17, 2020.

You asked the Plan to pay for the office visit. You say that this is your regular medical center. The Plan denied
your request. The Plan says the claim cannot be reprocessed until a corrected claim is received.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We looked at the file and the rules. The case file shows that a corrected claim is needed before the services can
be processed. Services must be submitted in a proper claim format in order to be considered for payment.
Based on this information, we decided that Medicare rules for coverage of the office visit have not been met.
Therefore, we decided that the Plan does not have to pay for the office visit provided on September 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction you had on January 22, 2021.

You asked the Plan to pay for the refraction. The Plan denied your request. The Plan says this is not a covered benefit.

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. The Plan covers one routine eye exam per year. 

We looked at the file and the Plan's rules. While the Plan covers one routine eye exam per year, refractions are not covered under the routine exam benefit. Based on this information, we decided that the Plan's rules for coverage of the refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction you had on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 26, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are available in-network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 lab services provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on September 14, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says plan benefits only cover manual manipulation of the spine to correct subluxation.
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.
We looked at the file and the rule. The office visit, when provided by a chiropractor, is not a covered benefit. The office visit is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of breast cancer and underwent reconstruction with implants. MRI is being requested to assess the integrity of the implants in an asymptomatic enrollee. Data in support of this indication is limited. The services are therefore not reasonable or medically necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on February 28, 2020, by an
out-of-network provider.

You asked the Plan to pay for the podiatry services. You say that the enrollee has an authorization on file at the
nursing facility for all care. The Plan denied your request. The Plan says you did not request 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 had network providers
available who could have provided 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 podiatry services provided on February 28, 2020, by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.

You asked the Plan to pre-approve proton treatment delivery; simple, without compensation (77520), Proton treatment delivery; intermediate (77523), Proton treatment delivery; simple, with compensation (77522), and Proton treatment delivery; complex (77525). You say that the cure rates, complication rates and survivability are all better with protons versus those of photons. The Plan denied your request. The Plan says the request is not for treatment in a clinical trial setting.

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 proton treatment delivery; simple, without compensation (77520), Proton treatment delivery; intermediate (77523), Proton treatment delivery; simple, with compensation (77522), and Proton treatment delivery; complex (77525). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per nccn radiation compendia proton beam is not compendia based for definitive therapy for very low risk disease.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton treatment delivery; simple, without compensation (77520), Proton treatment delivery; intermediate (77523), Proton treatment delivery; simple, with compensation (77522), and Proton treatment delivery; complex (77525) have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visits (97110) provided December 1, 2020 to December 29, 2020.

You asked the Plan to waive the copayment for the physical therapy visits. You say that this physical therapy has always been and should always continue to be paid at 100% of allowed amount by Medicare. Please correct this and pay the claim and provide a corrected EOB as required. The Plan denied your request. The Plan says the claims were processed and the correct copayments were applied per the Evidence of Coverage.

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 $40 copayment for each covered physical therapy, occupational therapy and speech/language therapy visit. 

You have been asked to pay $240 ($40 x 6 visits) for the physical therapy visits. The physical therapy visits fall within the Outpatient rehabilitation 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 physical therapy visits (97110) provided December 1, 2020 to December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says it is not reasonable to expect that you will be able to fully benefit from the intensity of services of 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 physician reviewer found that you were admitted to the acute care hospital for falls, confusion, pneumonia, and a urinary tract infection. Your medical problems are stable. There are no complex nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an Annual Wellness Visit provided on November 25, 2020.

You asked the Plan to pay for Annual Wellness Visit. You say that it is your understanding that the Plan covers
this service. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because an Annual Wellness Visit was already performed on March 11, 2020, so this benefit was exhausted.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once
every 12 months.

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Therefore, we decided that the Plan does not have to pay for an Annual Wellness Visit provided on November
25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 14, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the ordering provider's progress notes were not submitted.

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 documentation of the ordering physician's intent that the tests be performed. The submitted documentation did not contain progress notes from the ordering provider. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the brain (70553) provided on September 16, 2020.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 diagnostic radiology services other than CT scans. 

You have been asked to pay a $325 copayment for the diagnostic radiology service provided. 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 magnetic resonance imaging (MRI) of the brain (70553) provided on September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy (HBOT) visits (99183x20,
G0277x80).

You asked the Plan to pre-approve the HBOT visits. You say that the enrollee has left side cerebrovascular
accident and referred to your clinic to undergo HBOT and wound care to facilitate healing. You believe that
HBOT will help the enrollee heal faster and help avoid further complications. The Plan denied your request.
The Plan says the enrollee does not have any of the qualifying conditions and does not meet the Medicare
criteria for HBOT.

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 HBOT visits. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has had a stroke. A stroke is not a covered indication. The elements of the coverage
rule are not satisfied.

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 HBOT visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve hyperbaric oxygen therapy (HBOT) visits (99183x20, G0277x80).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for carpal tunnel surgery (64721) provided on November 6, 2020.

You asked the Plan to pay for carpal tunnel surgery. You say that this was performed twice, once on each side. The Plan denied your request. The Plan says this exceeds the MUE for this code.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 64721 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pay for carpal tunnel surgery (64721) provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for a periodic oral evaluation (D0120), bitewing x-rays (D0274) and a cleaning (D1110) provided on January 7, 2021 by an out-of-network provider.

You asked the Plan to pay the full amount for the out-of-network dental services. You say that your benefit highlights lead you to believe that these services would be paid in full by your Plan, regardless of whether they were provided in or out-of-network. The Plan denied your request. The Plan says your contract states that you may be billed by an out-of-network provider for any amount greater than the payment made by the Plan to the provider. Providers in the Plan's network have agreed to a negotiated rate that out-of-network providers have not. The Plan will only pay up to this negotiated rate for any covered service. If the provider chooses to charge an amount greater than this rate, you are responsible for the difference in cost. The Plan has paid the full allowed amount for these services up to the negotiated rate. You are responsible for the difference.

The rules say that 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 states that if you obtain dental services out-of-network, the Plan will pay up to a certain amount. If you choose to see an out-of-network dentist, you may be billed for any amount greater than what the Plan pays. This applies even for services listed with a $0 copayment.

You have been asked to pay $95 for the dental services provided on January 7, 2021. All of these services were covered, and part of this bill was paid for by the Plan. The Plan's allowed amount for these services, which is a rate that in-network providers have agreed to charge but out-of-network providers have not, is $119 total. The Plan paid the full allowed amount for these services, as they are each listed in the contract with a $0* copayment. (*If you choose to see an out-of-network dentist, you might be billed for charges above what the Plan pays, even for services listed as a $0 copayment.)

You used an out-of-network provider who did not agree to charge these rates for these services. The provider billed the Plan a total of $214 for the oral evaluation, cleaning and bitewing x-rays. You are responsible for the difference in cost between what the Plan is able to pay for these services and what the provider billed ($214 - $119 = $95). 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 that you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to pay the full amount for a periodic oral evaluation (D0120), bitewing x-rays (D0274) and a cleaning (D1110) provided on January 7, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a therapeutic monitor.

The Plan must follow Medicare rules. The rules say that only therapeutic continuous glucose monitors are covered. 

The requested monitor is not considered to be therapeutic. Therefore, it is not covered. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.