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

We decided that the Plan does not have to pre-approve Cinvanti (J0185) 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 this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Cinvanti is indicated and supported for use with highly and moderately emetogenic chemotherapy. Per the NCCN Guidelines Version 2.2020 Antiemesis page AE-3, Docetaxel has low emetogenic potential. Therefore the documentation does not support that Cinvanti is medically reasonable and necessary. The documentation does not support that the drug is safe and effective for the enrollee. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Cinvanti (J0185) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 16, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 8, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you are requesting an elimination of this charge. You say you attended the office visit at the insistence of the practice. 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 $20 copayment per primary care physician visit. You have been asked to pay a $20 copayment for the office visit. The office visit 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 office visit provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on December 11, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. 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, such as 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 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 a domiciliary, rest home visit provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 2, 2020 and January 23, 2020. You asked the Plan to waive the copayment for the office visits. You say that the visits were a follow up and a result of the surgery. You say that the copayments should be waived. The Plan denied your request. The Plan says the copayments 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 $50 for each Medicare-covered visit with an in-network specialist. You have been asked to pay a $50 copayment for each office visit. The total amount you owe is $100 ($50/visit x 2 visits = $100). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. There is no provision in the contract which indicates a copayment would be waived for services performed as a follow-up to 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 office visit provided on January 2, 2020 and January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultrasound therapy from a chiropractor. You asked the Plan to pre-approve these services. You say that you can't walk and are in pain. The Plan denied your request. The Plan says the services are not covered. 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. The records show that the service at issue is not manual manipulation of the spine. The requested services are ultrasound therapy. Therefore, we decided that the Plan does not have to pre-approve ultrasound therapy from a chiropractor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forself-administered drubs provided on August 3, 2019.You asked the Plan to pay forself-administered drugs. You say that the Plan should cover this bill.The Plan denied your request. The Plan says payment for self-administereddrugs must be submitted to your Medicare Part D carrier.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 pay forself-administered drugs provided on August 3, 2019.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatologist services provided on September 18, 2019 by an out of network (OON) provider. You asked the Plan to pay for dermatologist services. You say that these services used to be covered. The Plan
denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for these services. The plan says that the member changed provider networks on April 1, 2019. The Plan says that this provider is not in-network with the new 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for dermatologist services provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 16, 2019.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says there is no valid referral for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 medical services provided to the enrollee by an out-of-network provider on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-area medical services provided from September
18, 2019 to November 7, 2019.
You asked the Plan to pay for the out-of-area services. The Plan denied your request. The Plan says there was
sufficient time to return to the service area.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
We looked at the file, and Medicare rules. The file shows that the services at issue were provided 6 weeks after
the original diagnosis. There are insufficient medical records to show that the services were urgent or emergent.
Based on this information, we decided that Medicare rules for coverage of the out-of-area services have not
been met. Therefore, we decided that the Plan does not have to pay for the out-of-area medical services
provided from September 18, 2019 to November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level neurosurgeon.You asked the Plan to pre-approve these services. You say that your care team said it would be good for you to do a clinical trial.The Plan denied your request. The Plan says the tertiary level of care is not medically necessary.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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the records show that you have chronic back pain and a history of a laminectomy surgery. There are no current exam findings that would support a red flag for an immediate neurosurgery referral. Your primary care physician noted that your symptoms were fairly controlled. There are no imaging findings available for review. There is no documentation to support that a referral to tertiary care is 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 a referral to a tertiary-level neurosurgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray, three additional intraoral periapical x-rays, prophylaxis, and periodic oral evaluation provided on December 18,2019.You asked the Plan to pay for the intraoral periapical x-rays, prophylaxis, and periodic oral evaluation. You say that you are allowed two examinations and cleanings two times a year, and realized they were not 6 months apart. You also say that the record shows you were not billed for bite wings previously so these x-rays should bill as covered also.The Plan denied your request. The Plan says the intraoral periapical x-rays are not covered benefits. The Plan also says that your benefit maximum had been met for the prophylaxis and periodic oral evaluation.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 first intraoral periapical x-ray and each additional intraoral periapical x-ray are not among those covered under this benefit. The Plan contract says that cleanings and routine oral exams are each limited to once every six months. The record shows that you received a prophylaxis and periodic oral evaluation on July 22, 2019 and your benefit was then exhausted for the time period.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray, three additional intraoral periapical x-rays, prophylaxis, and periodic oral evaluation provided on December 18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat nuclear stress test.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a nuclear stress test is covered when specific criteria are met. 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 no symptoms suggestive of ischemia. The electrocardiogram changes are non-diagnostic and unchanged. There is no ischemia on prior stress testing. In this setting, repeat nuclear stress testing is not medically necessary and not the standard of care, as there are no documented covered indications for the procedure. 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 a repeat nuclear stress test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil Tab 20mg.
You asked the Plan to pre-approve Tadalafil Tab 20mg. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Tadalafil Tab 20mg.
Benefits for Tadalafil Tab 20mg may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the office visits provided on October 9, 2019 and November 18, 2019.
You asked the Plan to reduce the copayments for the office visits. You say that your copayment for an office visit is $10. You say you were not made aware that your provider became out-of-network. 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 $45 copayment for services obtained from an out-of-network primary care provider or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a primary care provider's office. You have been asked to pay a $45 copayment for each of the office visits. The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the provider is out-of-network.
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 reduce the copayments for the office visits provided by on October 9, 2019 and November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on November 22, 2019.You asked the Plan to reimburse you for the dental service. You say that you get 4 cleanings per year. You say that every other one is periodontal. You say that you had 2 prophylaxis cleanings, but those were covered by your regular dental insurance. You also say that the periodontal cleaning happened to fall at the end of of the year when your insurance ran out.The Plan denied your request. The Plan says periodontal maintenance is not a covered service. The Plan also says periodontal maintenance is not considered a preventive dental service.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, periodontal maintenance is not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you for the periodontal maintenance (D4910) provided on November 22, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown for tooth #13.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is not a
covered benefit.
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 a
crown for tooth #13.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99232) provided on October 10, 2019. You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because these charges are not a duplicate, bundled or inclusive to other charges billed. The Plan denied your request. The Plan says that services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code. The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the subsequent hospital care have been met. Specifically, this physician does not have the same specialty as the physician whose services were approved and paid. This physician's specialty is Internal Medicine Hematology & Oncology while the other physician's specialty is Internal Medicine Pulmonary Disease. Therefore, we decided that the Plan has to pay for subsequent hospital care (99232) provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for blood bank physician services (86076 26) provided on August 22, 2019.
You asked the Plan to pay for the blood bank physician services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 86076 has been billed with an invalid modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 86076 26 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 86076 has a PCTC indicator of 0. This means that this code is considered a physician service and modifiers 26 and TC are not appropriate. Based on this information, we decided that Medicare rules for coverage of the blood bank physician services have not been met. Therefore, we decided that the Plan does not have to pay for blood bank physician services (86076 26) provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on September 16, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 the physician's services provided on September 16, 2019.