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

We decided that the Plan does not have to pre-approve VECTIBIX 100MG/5ML Solution (CPT code J9303).
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says the medication is not 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 the medication. Our physician reviewer found the review indicates that the clinical value and effectiveness of VECTIBIX (panitumumab) in the setting of colon cancer without a negative/wild type rat sarcoma (RAS) mutation status have not been demonstrated in the peer-reviewed literature. VECTIBIX (panitumumab) is only supported for use in treating patients with negative/wild type RAS (KRAS and NRAS) mutation status. The provider has confirmed that you do not have a negative (wild-type) RAS (KRAS and NRAS) mutation status. The requested use of VECTIBIX Food and Drug Administration (FDA)-approved for your diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of Centers for Medicare and Medicaid Services (CMS)-approved journals).
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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve VECTIBIX 100MG/5ML Solution (CPT code J9303).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted due to stroke and subsequently developed hypoxic respiratory failure. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider
on January 18, 2021, February 1, 2021, and February 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you didn't know you had to get a referral to
keep seeing this doctor. The Plan denied your request. The Plan says this provider is not a network provider
with the Plan and the services were not approved in advance.
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. 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 laboratory services provided by an out-of-network
provider on January 18, 2021, February 1, 2021, and February 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on January 12, 2021.
You asked the Plan to pay for the complete maxillary and mandibular dentures. The Plan denied your request. The Plan says these services exceed the maximum allowed per period.
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, complete maxillary denture (D5110) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and complete mandibular denture (D5120) on
September 26, 2019 and your complete maxillary denture (D5110) and complete mandibular denture (D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 18, 2019, through October 19, 2019.

You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the stay is consistent with an observational level of care.

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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the enrollee presented to the emergency department due to shortness of breath and leg swelling. The enrollee developed dyspnea upon walking less than 150 feet. D-dimer was elevated, and a computerized tomography (CT) scan of the chest demonstrated bilateral pulmonary emboli. The enrollee had undergone lumbar fusion five weeks prior. The enrollee was at high risk for bleeding due to recent neurological surgery. The admitting physician made the determination to admit as an inpatient. The admitting physician had a reasonable expectation of an admission spanning two midnights. The medical record supports circumstances in which a less than two midnight stay would be appropriate for inpatient care. The elements of the coverage rule are 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 18, 2019, through October 19, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243).
You asked the Plan to pre-approve the intravenous sedation/analgesia. You say that the service is necessary. The Plan denied your request. The Plan says this service is not covered under the enrollee's dental 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 pre-approve intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239) and intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for the shoulder surgery (CPT code 23472), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 pre-approve 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 the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is listed under CPT code 23472 which is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. If the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information. The review has determined that there is no documentation indicating that the physician has a reasonable expectation that the necessary hospital care will 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 pre-approve inpatient hospital care for the shoulder surgery (CPT code 23472), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97530) provided on August 26, 2020.

You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for
the billed 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the record. Specifically, the record indicates that these
services were rendered in the member's home. There is a more appropriate CPT code for the rendered services.
Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not
been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities (97530) provided
on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT Code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 pre-approve the Vertiflex superion device placement surgery (CPT Code(s): 22869 and 22870), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the surgery services provided on December 4, 2020.
You asked the Plan to waive the cost share for the services provided. You say that the charges should be renegotiated. The Plan denied your request. The Plan says the cost share is a contractual obligation.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 10% coinsurance for outpatient surgery. You have been asked to pay a 10% coinsurance for the services provided. The services fall within the outpatient surgery 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 cost share for the surgery services provided on December 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0428, A0425) received December 30, 2020.

You asked the Plan to waive the copayment for the ambulance transportation. You say that you were told by the hospital staff that the Plan would waive the copayment for the ambulance transportation. The Plan denied your request. The Plan says the Plan is not responsible for benefit misinformation which may have been given to you by staff at a non-Plan hospital.

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 $200 copayment for Ambulance Services. 

You have been asked to pay a $164.38 copayment for the ambulance transportation. This is an amount less than the required $200 copayment for Ambulance Services. 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 ambulance transportation (A0428, A0425) received December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on
March 1, 2021.
You asked the Plan to pay for the home visit. You say that going to the doctor's office became more
problematic so medical physicians came to the facility. You say that it is in her best health interest to be seen at
the facility and the appeal should be granted. The Plan denied your request. The Plan says the services were not
referred by an in-network provider and there was no 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 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 home visit provided by an out-of-network
provider on March 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on February 10, 2021 by an OON provider.
You asked the Plan to pay for the subsequent nursing facility care. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the services were rendered by a non-contracted provider, and there is no indication that the services were ordered by a participating provider.
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 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 subsequent nursing facility care provided on February 10, 2021 by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the CDPAS.

You asked the Plan to pre-approve the CDPAS. The Plan denied your request. The Plan says consumer directed personal assistance services (CDPAS) are not a covered benefit.

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CDPAS have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve the CDPAS.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for optometry services provided on January 18, 2021 by an out of network (OON) provider.
You asked the Plan to pay for optometry services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for the services that were provided.
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. 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 optometry services provided on January 18, 2021 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an observation stay, a CT scan, and gastrointestinal blood loss imaging provided from February 12, 2021, to February 13, 2021.
You asked the Plan to waive the copayments for an observation stay, a CT scan, and gastrointestinal blood loss imaging. You say that you experienced hemorrhaging after a colonoscopy and feel that you should not be responsible for the charges. 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 $175
copayment for outpatient hospital observation. Your contract with the Plan also clearly says that you must pay a $200 copayment for diagnostic radiology. You had an observation stay from February 12, 2021, to February 13, 2021. Therefore, you are responsible to pay the $175 copayment. You received a CT scan and gastrointestinal blood loss imaging from February 12, 2021, to February 13, 2021. Therefore, you are responsible to pay the $200 copayment per each service. The total amount you owe for imaging is $400. The total amount you owe is: $575. You have been asked to pay the total copayment amount of $575 for an observation stay, a CT scan, and gastrointestinal blood loss imaging. An observation stay fall within the outpatient hospital observation benefit category. A CT scan, and gastrointestinal blood loss imaging fall within the outpatient diagnostic tests and therapeutic services and 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 copayments for an observation stay, a CT scan, and gastrointestinal blood loss imaging provided from February 12, 2021, to February 13, 2021.