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

We decided that the Plan does not have to pre-approve Carboplatin, Pembrolizumab, and Paclitaxel.

You asked the Plan to pre-approve Carboplatin, Pembrolizumab, and Paclitaxel. You say that the drugs are
medically necessary. The Plan denied your request. The Plan says at this time the requested Carboplatin,
Pembrolizumab, and Paclitaxel, is upheld as there is insufficient documentation that establishes medical
necessity.

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 Carboplatin, Pembrolizumab, and
Paclitaxel. Our reviewer says that the service is not medically necessary. Our physician reviewer found the
patient does not have recurrent or metastatic squamous cell carcinoma of the lung, and therefore, per
compendia, Carboplatin, Pembrolizumab, and Paclitaxel cannot be approved together.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Carboplatin, Pembrolizumab, and Paclitaxel have not been met. Specifically,
the enrollee, does not meet the requirements for Carboplatin, Pembrolizumab, and Paclitaxel to be used
together. This means the drugs are not medically necessary or reasonable. Therefore, we decided that the Plan
does not have to pre-approve Carboplatin, Pembrolizumab, and Paclitaxel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray exam of the foot (73630).

You asked the Plan to waive the copayment for the x-ray exam. You say that you did not have to pay for this service the last time you had it, and your podiatrist ordered the x-rays during a routine exam. The Plan denied your request. The Plan says you were not charged during your last visit because it was a few years ago and the Plan's contract at that time did not require a copayment for radiology services. However, x-ray exams are subject to a $20 copayment.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for x-rays and ultrasounds.

You have been asked to pay a $20 copayment for an x-ray exam of both feet. According to your 2020 contract, x-rays and ultrasounds require a $20 copayment. 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 x-ray exam of the foot (73630).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled nursing and therapy is not medically necessary.

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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating household distances. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).

You asked the Plan to pay for the shoulder elbow wrist hand orthosis. You say that this service was medically
necessary for the enrollee. The Plan denied your request. The Plan says there is no evidence that the provider
examined the enrollee prior to ordering the items.

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 pay for the shoulder elbow wrist hand orthosis. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found a physical examination of the shoulder would reasonably be required to
adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The
documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in
this case, as there is insufficient documentation of a credible physical examination of the shoulder.

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 shoulder elbow wrist hand orthosis have not been met. Therefore, we
decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis (L3960).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating
provider.

You asked the Plan to waive the copayment for lab work. You say that this lab work was done during your
annual wellness exam. You say that you do not agree with having to pay for the lab work. The Plan denied your
request. The Plan says the correct copayment has been 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 $5
copayment for outpatient diagnostic tests/laboratory tests.

You have been asked to pay a $5 copayment for lab work. When additional services are provided during an
annual wellness exam, additional copayments are applied; therefore, the correct copayment has been applied.
Lab work falls within the outpatient diagnostic tests/laboratory tests 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 lab work provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services provided from September 25, 2019, through September 27, 2019.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you have never been billed for a hospital stay before. The Plan denied your request. The Plan says that your 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 $295 copayment per day for Inpatient hospital care. You have been asked to pay a $590 copayment for the inpatient hospital services. The inpatient hospital services fall 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 the inpatient hospital services provided from September 25, 2019, through September 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider.

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you couldn't get your stress test done because you had a hospital approved breakfast. You say that you had to wait these additional days because of this. The Plan denied your request. The Plan says the correct copayment has been applied to the inpatient stay that was 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 per day for days 1-6. There is a $0 copayment for days 7-90 for inpatient hospital care/in-network.

You have been asked to pay a $325 copayment per day for days 1-3 for an inpatient hospital stay. The total amount you are being asked to pay is $975 ($325 x 3 days = $975). An inpatient hospital stay falls within the inpatient hospital care/in-network 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 provided by a participating provider.

We note your complaint about having to stay for three additional days because the test could not be done until then. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for neurological testing (95822, 95927, 95938).

You asked the Plan to pay for the neurological testing. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not eligible for separate payment.

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 codes 95822, 95927, & 95938 are not supported in the medical record. Specifically, the record shows the enrollee was an inpatient at the time services were provided. Payment for these services is included in the facility payment. Based on this information, we decided that Medicare rules for coverage of the neurological testing have not been met. Therefore, we decided that the Plan does not have to pay for neurological testing (95822, 95927, 95938).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for osteomyelitis of the left foot and had a left foot amputation. Her medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided at a low level of care.

Additionally, there is a not reasonable expectation that this patient will be able to fully participate in and benefit from an intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an office visit and an ECG provided by a
participating provider.

You asked the Plan to waive the coinsurance for an office visit and an ECG. You say that you thought that
paying your monthly premium would be all you had to pay. The Plan denied your request. The Plan says the
correct coinsurance has been 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 20%
coinsurance for outpatient diagnostic tests/diagnostic tests and physician/practitioner services/specialist.

You have been asked to pay a 20% coinsurance of the allowed amount for an office visit and an ECG. The total
allowed amount is $118.78. The total amount you are being asked to pay $23.76 ($118.78 x 20% = $23.76). An
office visit and an ECG fall within the outpatient diagnostic tests/diagnostic tests and physician/practitioner
services/specialist 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 an office visit and
an ECG provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a Fundus Photography exam.

You asked the Plan to pay for this service. You say that these vision services should be covered by the Plan. The Plan denied your request. The Plan says you received a Fundus Photography Exam. The Plan states this is not a covered service under your routine vision benefit.

Medicare 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 only cover routine vision services. A Fundus Photography exam is a digital image of the back portion of the eye and is not part of the routine vision exam covered by the Plan benefit. Therefore, we decided that the Plan does not have to pay for a Fundus Photography exam.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided to the enrollee and billed under DRG 853.

You asked the Plan to pay for this claim. You say that this service should be covered by the Plan as billed. The
Plan denied your request. The Plan says Medicare billing criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG. 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 this claim. Our reviewer says that Medicare coverage criteria are not met. Our
physician reviewer found the medical records show the enrollee presented to the hospital with vomiting, flank
pain, and nausea. It was found the enrollee had a urinary tract infection with sepsis as was described in the
notes for which she was admitted and treated. It was stated IV fluids resolved the vitals and symptoms and
remained stable the rest of the day. Severe sepsis with septic shock was listed but not supported in the
documentation as she responded to fluids relatively quickly. This would support a DRG of 854 as opposed to
the previously used DRG 853. Therefore, Medicare billing criteria are not met. We looked at this physician's
review, the file, and Medicare rules. Based on this information, we decided the medical records do not
substantiate DRG. Therefore, we decided that the Plan does not have to pay for inpatient care provided to the
enrollee and billed under DRG 853.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for x-rays and coinsurance for injections provided by a participating provider.

You asked the Plan to waive the deductible and coinsurance for x-rays and injections. You say that you do not agree with owing this much. The Plan denied your request. The Plan says the correct deductible and coinsurance has been 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 $975 deductible and a 20% coinsurance for Medicare Part B prescription drugs/in-network and outpatient diagnostic tests/in-network.

You have been asked to pay a $975 deductible and a 20% coinsurance of the allowed amount for injections. The total allowed amount is $26.10. The amount you are being asked to pay or injections is $5.22 ($26.10 x 20% = $5.22). The total amount you are being asked to pay is $98.59 ($5.22 (injections) + $54.87 (x-ray) + $38.50 (x-ray) = $98.59). The correct cost sharing amounts have been applied to the services that were provided. X-rays falls within the outpatient diagnostic tests/in-network benefit category and injections fall within the Medicare Part B prescription drugs/in-network 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 deductible for x-rays and coinsurance for injections provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation and follow up visits at a tertiary
care center.

You asked the Plan to pre-approve services at a tertiary care center. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not medically necessary at
this time as no medical records have been provided for review. The Plan says you can be seen at a community based
specialist of the same discipline with appropriate access and equivalent services.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.

We looked at the file and Medicare rules. In order to determine if a tertiary care center is medically necessary
compared to a community-based specialist of the same discipline, medical records are necessary for review. In
this case, the Plan made attempts to obtain medical records from your past physicians with no success. Based
on this information, we decided that Medicare rules for coverage of services at a tertiary care center have not
been met. Therefore, we decided that the Plan does not have to pre-approve an office consultation and follow
up visits at a tertiary care center.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care provided to the enrollee.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says custodial care is not
covered.

The Plan must follow Medicare rules. Medicare rules say that custodial care is excluded from coverage.

We looked at the file and Medicare rules. The enrollee was provided custodial care. Custodial care is not covered by Medicare or the enrollee's plan. 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 for the custodial care provided to the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the brain.

You asked the Plan to pre-approve the MRA of the brain. You say that the records provided support the need for the request brain MRA. The Plan denied your request. The Plan says the doctor's notes do not talk about other tests the enrollee has had for this problem. The Plan says that the notes should say what has been done to help the enrollee and why other tests cannot be done first. 

The Plan says that they also need to know how the requested test will change how the doctor treats the enrollee.
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 MRA of the brain. Our reviewer says that the requested MRA of the brain is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is not noted to be suspected to have a condition for which surgery is otherwise anticipated. They are not suspected of having a tumor, aneurysms, vascular malformations, acute vascular occlusion or thrombosis. Rather, the test was ordered more to evaluate for atherosclerotic changes, which is not an indication for which Medicare otherwise covers this service.

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 MRA of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) of the brain.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for The Guardant360 testing.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services do
not meet the diagnosis code relationship.

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 looked at the file and the rules. We find that the testing at issue was not billed with the correct CPT code or
unit of service. Based on this information, we decided that Medicare rules for coverage of the testing services
have not been met. Therefore, we decided that the Plan does not have to pay for The Guardant360 testing.