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

We decided that the Plan does not have to pre-approve Polivy. You asked the Plan to pre-approve Polivy. The Plan denied your request. The Plan says Polivy has to be used in combination with Bendamustine and Rituximab. 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 Polivy. Our physician reviewer found that the request is for Polivy to be given with Rituximab hycela to treat relapsed diffuse large B-cell lymphoma. The enrollee has been treated with multiple regimens including stem cell transplant. The drug is not FDA approved for use in the requested combination. The requested use is supported by the NCCN compendium if the enrollee is not a transplant candidate. The compendium states: Preferred as a single agent or in combination with Bendamustine and/or Rituximab as second-line or subsequent therapy for partial response, no response, relapsed, progressive or refractory disease after at least 2 prior therapies in non-candidates for transplant..However, the submitted documentation does not indicate whether the enrollee is a candidate for transplant at this time. The documentation also does not indicate the response achieved with the use of the Polivy combination in 2019 nor whether it was stopped due to progression of the lymphoma. Therefore, the requested drug is not medically reasonable or 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 Polivy have not been met. Therefore, we decided that the Plan does not have to pre-approve Polivy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on November 19, 2019. You asked the Plan to waive the copayment for the arthrocentesis. You say that you didn't have anesthesia for this to be a surgery. You say that this was a leg injection you received in the doctor's office. The Plan denied your request. The Plan says the copayment applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility. You have been asked to pay a $250 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The arthrocentesis is considered a surgical procedure. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the arthrocentesis provided on November 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 5, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for laboratory services provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening laboratory testing provided on August 27, 2019. 
 
You asked the Plan to pay for lab tests. You say that you are appealing with records to support medical necessity. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the tests at issue were requested solely for screening purposes and are not covered by Medicare. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 
 
The tests at issue in this appeal, lab tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening laboratory testing provided on August 27, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services (G0156). You asked the Plan to pre-approve home health services. You say that the services are necessary. The Plan denied your request. The Plan says the provider does not bill Medicare. Therefore, coverage criteria has not been met. The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services (G0156).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. You asked the Plan to pre-approve continued SNF care. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for inpatient services after June 7, 2020. Care in the long-term care facility with intermittent services or in the home with home health services appears to be appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the vision services provided on March 14, 2019.
You asked the Plan to waive the deductible for the vision services. You say that you were told the provider was in-network. You say you did nothing wrong in this matter and that the health plan should settle this. 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. Your contract with the Plan says that there is a $700 deductible that applies towards out-of-network vision services.
The vision services you asked the Plan to waive the deductible for falls within the "Vision services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $700 deductible that applies towards out-of-network vision services. The record shows that the provider is out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the vision services was received on March 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the vision services provided on March 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 21, 2019 through August 31, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from August 21, 2019 through August 31, 2019. You are asked to pay a $175 copayment for the inpatient hospital care. 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 inpatient hospital care from August 21, 2019 through August 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forear buds purchased on January 17, 2020.You asked the Plan to pay forthe ear buds. You say that this should be covered completely per your policy.ThePlan denied your request. The Plan says there is no coverage of hearing aids or related services if they are received from a provider that is not part of the plan's hearing aid vendor's network.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. The Plan pays for hearing aids only when they are provided by the plan's hearing aid vendor. The ear buds were not purchased from the plan's hearing aid vendor. Based on this information, we decided that the Plan's rules for coverage of the ear buds have not been met.Therefore, we decided that the Plan does not have to pay forear buds purchased on January 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 19, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that 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, suchas 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 servicesat 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 laboratory services provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 16, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you would like this claim reprocessed because you have out-of-network benefits. The Plan denied your request. The Plan says services are not a covered benefit when performed by a dentist who has affirmatively opted out of Medicare participation.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the treating provider. This provider has opted out of the Medicare program. The file shows that the treating provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on January 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forlab services (CPT 80305) provided to the enrollee on August 19, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe provider is no longer credentialed or eligible for Medicare/Medicaid billing of services.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 80305 is "Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service."We find that CPT code 80305 is not supported in the medical record. Specifically, the provider of this service is no longer credentialed, so the service cannot be billed and paid for. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forlab services (CPT 80305) provided to the enrollee on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have a bone spur on your heel and when you walk it hurts. You say that the requested orthotics are needed to help relieve your pain while walking. You stated that you would like to have the requested orthotics to avoid potential surgery in the future. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power mobility device.You asked the Plan to pre-approvea power mobility device. You say that because of your medical condition you need a power scooter.The Plan denied your request. The Plan says you have not completed the necessary evaluations for approval of this device.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or you can safely operate the PMD being requested. There is no physician order, face-to-face documentation, or home assessment. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker reading provided on
April 6, 2020.
You asked the Plan to waive the copayment for the remote pacemaker reading. You say that you do not go into
the office for the pacemaker checks and they are done over the phone. You say you have never had to pay this
before and you do not believe you should be charged. 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 $35
copayment per visit to a specialist.
You have been asked to pay a $35 copayment for the remote pacemaker reading. The remote pacemaker
reading falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the remote pacemaker reading provided on April 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Urinary Collection System.
You asked the Plan to pre-approve these services. You say that this is medically necessary for you. The Plan denied your request. The Plan says that this is not covered under your Medicare plan.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a Urinary Collection System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.You asked the Plan to pre-approve a continuous glucose monitor. You say that a continuous glucose monitor would help you keep up with your blood sugar without the hassle of needles.The Plan denied your request. The Plan says you are not insulin treated three or more times a day or frequently adjusting dosage based on testing results.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The record shows you are not insulin injecting three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring System.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the annual health club membership purchased on
January 23, 2020 from an out-of-network facility.
You asked the Plan to reimburse for the annual health club membership. You say that you are requesting
reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-ofnetwork
benefits.
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 reimburse for care from out-of-network providers only in cases involving
emergencies, out of area urgent care and pre-approved care.
The gym membership is covered at a $0 copayment when you utilize a participating fitness facility. 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 reimburse for these items/services.
Therefore, we decided that the Plan does not have to reimburse for the annual health club membership
purchased on January 23, 2020 from an out-of-network facility.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient readmission from April 3, 2019 through April 6, 2019.
You asked the Plan to pay for the inpatient readmission. The Plan denied your request. The Plan says that the expenses from the admission should be included with the last admission.
The Plan follows Medicare rules. Medicare rules say that readmission review involves admissions to an acute, general, short-term hospital occurring less than 31 calendar days from the date of discharge from the same or another acute, general, short-term hospital. 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 inpatient readmission. Our reviewer says that the inpatient readmission was considered medically reasonable and necessary for the enrollee in this case. The readmission did not result from a premature discharge from the same hospital. The enrollee was stable on post-operative evaluation on March 26, 2019. The symptom complex that began on April 3, 2019 represented new medical conditions. Our physician reviewer found that the enrollee's condition met Medicare criteria for inpatient readmission. 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 inpatient readmission have been met. Therefore, we decided that the Plan has to pay for the inpatient readmission from April 3, 2019 through April 6, 2019.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of inpatient mental health services after March 12, 2020.
You asked the Plan to pre-approve the inpatient mental health services. You say that the services are medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that continued inpatient level care is not medically necessary. Our physician reviewer found upon review the records provided, this patient does not meet the criteria for acute inpatient mental health treatment beyond March 12, 2020 and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression. 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 inpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of inpatient mental health services after March 12, 2020.