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

We decided that the Plan does not have to waive the copayment for an ultrasound provided on October 24, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you were not informed before the procedure that you would owe a copayment. 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 $110 copayment for each ultrasound. You have been asked to pay a $110 copayment for an ultrasound. An ultrasound falls 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 copayment for an ultrasound provided on October 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. 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. 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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and non-emergency transport from your residence to the dialysis center provided on October 7, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee was in a hospital-based dialysis center for a dialysis appointment. You say that this was not related to the enrollee's hospice diagnosis. You also say that this should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and non-emergency transport from your residence to the dialysis center provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the surgical procedure provided on
December 2, 2020.
You asked the Plan to waive the deductible for the after cataract laser surgery (66821). You say that your
surgeon told you that you would only have a copayment for the procedure. The Plan denied your request. The
Plan says you had not met your deductible at the time of the procedure.
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 $750 deductible for covered services.
The item or service you asked the Plan to waive the deductible for falls under the deductible covered medical
services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750
deductible for this type of medical service. This cost sharing is a contractual obligation that had not been met at
the time the after cataract laser surgery (66821) was received on December 2, 2020. Therefore, we decided that
the Plan does not have to waive the deductible for the surgical procedure provided on December 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
You asked the Plan to pre-approve the physical therapy. You say that you joined this program for osteoporosis in November 2019 and you have been paying out of pocket. You say this provider is an exercise program with four machines and other equipment. You say that your bone density scans have improved since going to this provider, and you were told that it will take more time for more improvement. The Plan denied your request. The Plan says out-of-network services, unless emergent in nature or not available within your Medical Group network, are not considered medically necessary.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the out-of-network provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that these supplies are necessary and should be covered. The Plan denied your request. The Plan says this item is not a covered benefit.
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 incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral nutrition supplies provided from November 1,
2020, to November 30, 2020.
You asked the Plan to pay for the enteral nutrition supplies. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says Medicare rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF to be a home. Medicare rules say that
Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to an
enrollee.
Records show that the enteral nutrition supplies was used in a SNF. The facility must furnish all necessary
covered supplies to the beneficiary either directly or under arrangements made with outside providers. These
supplies would have been included in the global payment submitted to the plan by the facility. If the health plan
is not covering the SNF stay, the cost of these supplies is absorbed by the facility. Payment for this claim must
be submitted to the facility for payment, not the health plan.
Therefore, we decided that the Plan does not have to pay for the enteral nutrition supplies provided from
November 1, 2020, to November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transesophageal echocardiography (CPT 93355) provided to the enrollee on October 19, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the benefit for this service is already included in the payment/allowance for another service/procedure that has already been adjudicated.
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 93355 is "Echocardiography, transesophageal (TEE) for guidance of a transcatheter intracardiac or great vessel(s) structural intervention(s) (eg, TAVR, transcatheter pulmonary valve replacement, mitral valve repair, paravalvular regurgitation repair, left atrial appendage occlusion/closure, ventricular septal defect closure) (peri-and intra-procedural), real-time image acquisition and documentation, guidance with quantitative measurements, probe manipulation, interpretation, and report, including diagnostic transesophageal echocardiography and, when performed, administration of ultrasound contrast, Doppler, color flow, and 3D." 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found that in this case, the enrollee underwent cardiac bypass surgery. The requested CPT code describes transesophageal echocardiogram during transcatheter procedures. The elements of the requested procedure are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for transesophageal echocardiography (CPT 93355) provided to the enrollee on October 19, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the transrectal ultrasound described by current procedural terminology (CPT) code 76872 provided on November 18, 2020.
You asked the Plan to pay for CPT code 76872. You say that the medical records support the billing of CPT code 76872. The Plan denied your request. The Plan says that the medical records do not support the billing of CPT code 76872.
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 76872 is Ultrasound, transrectal. We find that CPT code 76872 is supported in the medical record. Specifically, the file contains the ultrasound provided and the procedure note includes that a transrectal ultrasound probe was placed during the procedure. Based on this information, we decided that Medicare rules for coverage of CPT code 76872 have been met. Therefore, we decided that the Plan has to pay for the transrectal ultrasound described by current procedural terminology (CPT) code 76872 provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic service described by current
procedural terminology (CPT) code 98943 provided on February 1, 2021.
You asked the Plan to pay for CPT code 98943. You say that you would like the Plan to reconsider their denial
of payment. 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. Therefore, we decided that
the Plan does not have to pay for the non-covered chiropractic service described by current procedural
terminology (CPT) code 98943 provided on February 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent.
You asked the Plan to pre-approve Praluent. You say that this request is medically necessary. The Plan denied your request. The Plan says drug coverage is limited only to those drugs covered under the enrollee's medical benefit.
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 Praluent.
Benefits for Praluent 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the anti-reflective coating (V2750), the progressive lens per lens (V2781), and the polycarbonate lens (V2784) received September 24, 2020.

You asked the Plan to pay for the eyeglass lens upgrades (V2750, V2781, V2784). You say that you were directed to this provider therefore the Plan should pay the claim. The Plan denied your request. The Plan says you are responsible for the cost of all lens upgrades.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The Plan does not cover lens upgrades. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating (V2750), the progressive lens per lens (V2781), and the polycarbonate lens (V2784) received September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied your request. The Plan says the requested drug is not medically 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 Keytruda. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with adenoma of the ampulla of Vater. In this case, Keytruda has not been FDA-approved for the enrollee's diagnosis. In addition, the use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. There is not enough data and no phase III based on PD-L1 expression as criteria for use. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage and the non-emergency transport provided on October 7, 2020.
You asked the Plan to pay for the transportation services. You say that the enrollee is hospice based on health plan eligibility. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage and the non-emergency transport provided on October 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
You asked the Plan to pre-approve additional mileage for routine transportation trips. You say that the additional mileage is needed. The Plan denied your request. The Plan says the requested additional mileage exceeds the benefit limit. Therefore, coverage criteria have not been met.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 24 one-way transportation trips per calendar year when each one-way trip does not exceed 50 miles. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional mileage for routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the inpatient stay provided from September 2, 2020, through September 18, 2020.

You asked the Plan to waive the co-payment for the inpatient stay. You say that you had to stay in the hospital for more surgeries. You say that you shouldn't be responsible for the $1,500. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 co-payment per day for days 1-7 and a $0 co-payment per day for days 8-90 for each medically necessary covered inpatient stay. A cost-sharing is charged for each inpatient stay.

You have been asked to pay a $1,750 co-payment for the inpatient stay. ($250/day x 7 days = $1,750). The inpatient stay falls 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 co-payment for the inpatient stay provided from September 2, 2020, through September 18, 2020.

Your complaint about the surgeon causing more surgeries is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for treatment of an infection of the knee. The enrollee's 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from November 27, 2019, to December 1, 2019, and billed with DRG 871.
You asked the Plan to pay for inpatient care provided billed with DRG 871. You say that the billed DRG is correct. The Plan denied your request. The Plan says the records support DRG 194 instead of 871.
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, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871, septicemia or severe sepsis without mechanical ventilation greater than 96 hours with major complications or comorbidities. 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 inpatient care provided billed with DRG 871. Our reviewer says that DRG 871 is not supported. Our physician reviewer found in this case, the DRG 871 is based upon a principal diagnosis code assignment of A41.9, Sepsis, Unspecified organism. The enrollee was admitted with
fever, pneumonia, and tachypnea. The hypoxia was documented to be secondary to asthma exacerbation. Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. There is insufficient evidence of end-organ dysfunction. The provided documentation does not support the presence of sepsis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from November 27, 2019, to December 1, 2019, and billed with DRG 871.