Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herzuma 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 request does not meet the step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 the case file does not contain documenation of trail and failure of Herceptin (trastuzumab), OR a biosimilar of Herceptin - Kanjinti (trastuzumab-anns) and Trazimera (trastuzumab-qyyp). The documentation does not support that these drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.

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 Herzuma for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two oral evaluations and two cleanings provided on March 11, 2020, and November 2, 2020 by an OON provider.
You asked the Plan to pay for the oral evaluations and cleanings. You say that these services are preventive. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that services rendered by a non-participating dentist are not a covered benefit under your plan.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two oral evaluations and two cleanings provided on March 11, 2020, and November 2, 2020 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (CPT 99153) provided to the enrollee on December 4, 2019.
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 CPT code 99153 is not supported in the records.
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 99153 is "Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)." We asked our coding 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 coding reviewer found the operative report did not include documentation of moderate sedation, and the presence of an independent trained observer to assist in monitoring. When reporting a procedure, documentation must support all criteria in the description of the code being reported to confirm services where provided. We looked at this coder'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 moderate sedation services (CPT 99153) provided to the enrollee on December 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing facility stay provided by a participating provider on September 1, 2020, to September 13, 2020.
You asked the Plan to waive the copayment for a skilled nursing facility stay. You say that you do not agree with this copayment. 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 $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing facility (SNF) care. You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-27 for a skilled nursing facility stay. The total amount you are being asked to pay is $1,068 ($178 x 6 days = $1,068). A skilled nursing facility stay falls within the skilled nursing facility (SNF) 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 a skilled nursing facility stay provided by a participating provider on September 1, 2020, to September 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for biomarker testing services provided on July 9, 2020.
You asked the Plan to pay for biomarker testing services. You say that these services are medically necessary to direct the enrollee's treatment plan. The Plan denied your request. The Plan says rules for payment have not been met.
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 biomarker testing services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Medicare-approved compendia state that it is unclear whether gene expression profiling provides clinically actionable prognostic information when used in addition to known clinicopathologic factors or multivariable nomograms. Furthermore, the impact of such testing on treatment outcomes or follow-up schedules has not been established. It has not been adequately demonstrated that the testing will impact the management and outcome of the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of biomarker testing services have not been met. Therefore, we decided that the Plan does not have to pay for biomarker testing services provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational for the treatment of osteoarthritis.
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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the procedure is considered an experimental/investigational procedure and is the subject of on-going clinical trials. Therefore, the request is considered not medically reasonable or necessary. 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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office consultation (99245) and the Physical Therapy (PT) (97110).

You asked the Plan to waive the copayment for the office consultation and PT services. You say that you were not happy with the services and therefore should not be charged copayments. The Plan denied your request. The Plan says the copayments were 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 $50 copayment for a specialist visit. The Plan contract also says that enrollees must pay a $20 copayment for outpatient rehabilitation services.

You have been asked to pay a $50 copayment for the office consultation and a $20 copayment for the PT services. The office consultation falls within the Physician/Practitioner services, including doctor's office visits benefit category. The PT services fall within the Outpatient rehabilitation 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 office consultation (99245) and the Physical Therapy (PT) (97110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the all-inclusive clinic visit (T1015) provided on October 6, 2020.
You asked the Plan to pay for the clinic visit. You say that you need to get teeth removed and get a new plate or dentures. You say that at your appointment you only had a cleaning and x-ray. You say that you did not get any other services for you to get new dentures. You also say that you cannot pay for this service out of pocket. The Plan denied your request. The Plan says all-inclusive clinic visit is not listed as a covered 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the all-inclusive clinic visit (T1015) provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating hospital on October 13, 2020.
You asked the Plan to waive the copayment for lab work. You say that you did not know that this was considered an outpatient hospital. 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 $35 copayment for outpatient diagnostic tests/lab services outpatient hospital facility. You have been asked to pay a $35 copayment for lab work. The correct copayment has been applied to the lab work that was provided in an outpatient hospital setting. Lab work falls within the outpatient diagnostic tests/lab services outpatient hospital facility 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 hospital on October 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0274, D0220, D0230, and D1999) provided on July 29, 2020.
You asked the Plan to pay for dental services. You say that you were told you these services were covered and cannot pay this amount. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan's dental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental services (D0274, D0220, D0230, and D1999) provided on July 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that by the enrollee was clearly stable for transfer to a plan facility. After presenting to the medical center with CVA symptoms of right upper and right lower extremity weakness and slurred speech, the enrollee was successfully treated in the ED with TPN with the enrollee noting that he, "essentially feels back to normal" the following day. A follow-up head scan revealed, "No intracranial hemorrhage." At this time, the enrollee was back to baseline with "no complaints" and he had an unremarkable follow up MRI scan. All inpatient care provided was not needed on an emergent basis. The treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered experimental/investigational because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery (22869, 22870).
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested interspinous process spacer device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee is not insulin treated. 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 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five core buildups, including any pins when required (D2950 x5), surgical procedure for isolation of tooth (D3910), canal preparation and fitting (D3950), two osseous surgeries (D4260 x2), two bone replacement grafts (D4263 x2), and two guided tissue regenerations (D4266 x2).
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit plan.
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 five core buildups, including any pins when required (D2950 x5), surgical procedure for isolation of tooth (D3910), canal preparation and fitting (D3950), two osseous surgeries (D4260 x2), two bone replacement grafts (D4263 x2), and two guided tissue regenerations (D4266 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 19, 2020 by an out of network (OON) provider.
You asked the Plan to pay for discharge management visit. You say that the enrollee was in observation and did not require an authorization for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan, the rendering facility is also out-of-network with the Plan, this service was not urgent or emergent, and authorization was 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. The record shows that this service was provided after the course of the enrollee's emergency care had concluded and the enrollee was in observation status. 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 medical services provided on September 19, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), electrical stimulation therapy (97014), and the neuromuscular reeducation (97112).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy or by Medicare.

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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit (99203), electrical stimulation therapy (97014), and the neuromuscular reeducation (97112).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 15734) provided to the enrollee on September 25, 2020.
You asked the Plan to pay for the services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service billed.
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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk (15734)." We asked our coding 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 coding reviewer found the medical records submitted do not include sufficient documentation to validate that a Muscle, myocutaneous, or fasciocutaneous flap; trunk was performed on September 25, 2020. 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 surgical services (CPT 15734) provided to the enrollee on September 25, 2020.