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

We decided that the Plan does not have to pre-approve Xofigo.
You asked the Plan to pre-approve Xofigo. You say that the requested Xofigo is medically necessary. The Plan denied your request. The Plan says the requested Xofigo 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 Xofigo. Our reviewer says that the requested Xofigo is not medically necessary. Our physician reviewer found the Food and Drug Administration and NCCN guidelines indicate that Xofigo is indicated for the treatment of patients with castration-resistant prostate cancer, symptomatic bone metastases and no known visceral metastatic disease. In this case, the medical record indicates that the enrollee has visceral metastatic disease. The elements of the coverage criteria 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 Xofigo have not been met. Therefore, we decided that the Plan does not have to pre-approve Xofigo.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.
You asked the Plan to pre-approve a SNF admission. You say that the enrollee is a fall risk and will need supervision until his endurance and strength improve. The Plan denied your request. The Plan says the enrollee is receiving adequate care in the Inpatient Rehab Facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676) half-leg appliance (E0673) provided on July 7, 2020.

You asked the Plan to pay for a pneumatic compression device. You say that this was medically necessary. The Plan denied your request. The Plan says the denial of payment for this item is correct, because a pneumatic compression device and/or supplies is not covered to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service and is not covered by Medicare. The rules state that PCD related accessories are only covered if the base PCD is covered. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD appliance have not been met. Specifically, the base PCD is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Because the base PCD is not covered, this PCD related accessory is also not covered. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676) half-leg appliance (E0673) provided on July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benlysta.
You asked the Plan to pre-approve Benlysta. You say that the requested Benlysta is medically necessary. The Plan denied your request. The Plan says the requested Benlysta is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Benlysta. Our reviewer says that the requested Benlysta is not medically necessary. Our physician reviewer found in this case, the order for the requested drug indicates that the enrollee has systemic lupus erythematosus. The medical records do not support this diagnosis and indicate the enrollee has inflammatory polyarthritis. The record does not indicate a diagnosis of rheumatoid arthritis. The elements of the coverage rule as indicated by the Medicare Drug compendia 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 Benlysta have not been met. Therefore, we decided that the Plan does not have to pre-approve Benlysta.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 2, 2020 by an out of network provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 services at issue in this appeal. The Plan did not pre-approve the service 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 subsequent nursing facility care provided on November 2, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0482) provided on July 1, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the submitted claim was billed with a laboratory place of service code while the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0482) provided on July 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on November 17, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this service would be included in the facility PPS payment.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to these services would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated Thoracic Lumbar Sacral Orthoses (TLSO) (L0482).
You asked the Plan to pre-approve a custom fabricated TLSO (L0482). You say that the requested custom fabricated TLSO (L0482) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested custom fabricated TLSO (L0482).
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 a custom fabricated TLSO (L0482). Our reviewer says that the enrollee does not meet criteria for the requested custom fabricated TLSO (L0482). Our physician reviewer found in this case, the enrollee has lumbar compression fractures that have progressed and requires the brace for stability purposes. The provided record contains insufficient documentation of the rationale for the need for the custom brace. There is no functional evaluation by the orthotist included in the case file. The elements of the coverage determination 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 a custom fabricated TLSO (L0482) have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated Thoracic Lumbar Sacral Orthoses (TLSO) (L0482).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on October 19, 2020.
You asked the Plan to pay for the office visit. You say that you were informed the appeal was approved but have yet to receive payment. The Plan denied your request. The Plan says prior authorization was required but not obtained.
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 office visit provided by an out-of-network provider on October 19, 2020.
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.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for altered mental status and was discharged home on 5/2/21 with home health services. There is ongoing weakness. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 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.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after March 30, 2021.
You asked the Plan to pre-approve continued SNF services. You say that potential for discharge is directly related to anticipated improvement in condition and availability of 24/7 home care. The Plan denied your request. The Plan says SNF services were not medically necessary after March 30, 2021.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services after March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on October 15, 2020 the telehealth visit provided on November 23, 2020.

You asked the Plan to waive the copayment for the telehealth visits. You say that this was a telehealth visit due to COVID. You say that it is your understanding the copayments for telehealth are 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 a $35 copayment for services received from an in-network Level 1 specialist physician. 

You have been asked to pay a $35 copayment for each telehealth visit. The total amount you owe is $70 ($35/visit x 2 visits = $70). The telehealth visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan says that only copayments for primary care physician visits and behavioral health visits related to COVID are being waived. 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 telehealth visit provided on October 15, 2020 the telehealth visit provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit you had on November 4, 2020.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible for the cost share.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for services received from a Level 1 Specialist physician. 

Review of the file shows that you had a specialist visit for an eye exam on November 4, 2020. You have been asked to pay a $35 copayment for the visit. The visit falls within the physician services 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 specialist visit you had on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the set up and transport of x-ray equipment with current procedural terminology (CPT) codes Q0092 and R0075 provided on August 14, 2020.
You asked the Plan to pay for CPT codes Q0092 and R0075. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure codes Q0092 and R0075 were provided in a facility with a place of service code of 31. Procedure codes Q0092 and R0075 have a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the set up and transport of x-ray equipment with current procedural terminology (CPT) codes Q0092 and R0075 provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and the endoscopies provided on November 3, 2020 to December 4, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the office visits and the endoscopies. You say that you have been seeing this provider for over a year and have never been denied coverage before. The Plan denied your request. The Plan says no prior authorization was obtained.

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 office visits and endoscopies provided on November 3, 2020 to December 4, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system (E2300).

You asked the Plan to pre-approve a power seat elevation system (E2300). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says a power seat elevation system (E2300) is statutorily non-covered by Medicare and the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Medicare specifically excludes coverage of power seat elevation systems coded as E2300. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) provided September 28, 2020.

You asked the Plan to pay for the segmental gradient pressure pneumatic appliance. You say that the services performed were medically necessary The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient 

The enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance, half leg (E0673) provided September 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 26, 2020.

You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 26, 2020. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 26, 2020.