Persius/hicric huggingface dataset:
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 the enrollee has tried other drugs. The Plan denied your request. The Plan says there is no evidence to support the use of maintenance Keytruda after doublet therapy.
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 this drug is not reasonable and necessary. Our physician reviewer found the requested use of Keytruda is not FDA approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is approved for progression after platinum based therapy. The enrollee has not progressed after platinum based therapy. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.You asked the Plan to pre-approve the compression stockings. You say that you require the stockings to keep the swelling in your arm down.The Plan denied your request. The Plan says gradient compression stockings listed by codes A6530, A6533-A6544, A6549 are notcovered for all indications.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a colonoscopy provided on December 6, 2019.
You asked the Plan to waive the deductible for a colonoscopy. You say that the colonoscopy should be considered a screening even though you had polyps removed. 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. Your contract with the Plan says that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that polyps were removed during a colonoscopy provided on December 6, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $154.63 toward the $750 deductible at the time services were rendered. Therefore, you are responsible to pay the total allowed amount of $367.91. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on December 6, 2019. Therefore, we decided that the Plan does not have to waive the deductible for a colonoscopy provided on December 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.You asked the Plan to pre-approve a CGM. You say that your fingers are calloused and it is hard to finger stick test.The Plan denied your request. The Plan says criteria is not met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The record shows you are not insulin treated. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 11, 2019
through November 13, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The
Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review has determined that the record showed that at the time of inpatient admission the
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from November 11, 2019 through November 13, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care from November 1, 2019 through November 19, 2019 provided by an out-of-network provider.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under Original Medicare.
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 dates of service at issue in this appeal. The member was enrolled in hospice from September 8, 2019 through November 1, 2019. Therefore, we decided that the Plan does not have to pay for inpatient hospital care from November 1, 2019 through November 19, 2019 provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from September 3, 2019 through September 19, 2019. You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided the enrollee no longer qualified for SNF coverage after September 2, 2019. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, AL, LTC). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from September 3, 2019 through September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the Part B injections and the x-ray provided from February 18, 2019 to February 22, 2019. You asked the Plan to reduce the cost share for the Part B injections and the x-ray. You say that you should only be responsible for $370.40 because you only received the medication once. 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 20% coinsurance for all other drugs covered under Medicare Part B and a $35 copayment for x-ray. You have been asked to pay a total of $775.80 for the Part B injections and the x-ray. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. The x-ray 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 reduce the cost share for the Part B injections and the x-ray provided from February 18, 2019 to February 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring (CGM) system.You asked the Plan to pre-approvea CGM. You say that the enrollee needs a CGM.The Plan denied your request. The Plan says the enrollee does not meet the criteria.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The record shows the enrollee does not test four or more times a day and is not insulin treated three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approvea FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lightweight wheelchair.
You asked the Plan to pre-approve a lightweight wheelchair. You say that your current wheelchair is too small and the tires are falling apart. The Plan denied your request. The Plan says the record shows you can self-propel a standard wheelchair and there is no repair estimate for your current wheelchair.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a standard wheelchair. Your standard wheelchair serves the same purpose as a lightweight wheelchair and the record shows you can propel the standard wheelchair. There is no documentation of your current wheelchair needing repairs. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair.
Appeal type: Lab
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 November 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the denture reline provided on October 14, 2019.
You asked the Plan to pay for the denture reline. You say that you checked with the Plan for an in-network provider prior to having services rendered. You also say that you chose a provider off of the in-network list that the Plan provided to you. The Plan denied your request. The Plan says that this service is not covered by 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. We looked at the file and Medicare rules. Although the service was billed for an unspecified removable prosthodontic procedure (D5899), the Plan confirmed with the provider that you received a reline of a complete maxillary denture (D5730), which is a covered benefit under your plan. We find that you reasonably expected the service you were receiving to be covered based on the language of your contract. Based on this information, we decided that the Plan's rules for coverage of the denture reline have been met. Therefore, we decided that the Plan has to pay for the denture reline provided on October 14, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on October 22, 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 October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 29, 2019 through October 4, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were charged two full copayments for the transfer. You say that paying two copayments is not manageable. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment each day for days 1 to 5 for Medicare-covered hospital care and a $0 copayment for additional Medicare-covered days. You have been asked to pay a $1,250 copayment for the inpatient stay. ($250/day x 5 days = $1,250). The inpatient stay falls within the "Inpatient Hospital Care" benefit category. A transfer is considered a new admission. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from September 29, 2019 through October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 genetic testing provided on August 26, 2019.
You asked the Plan to pay for Guardant360 testing. You say that this testing was ordered by the treating physician to determine the optimal treatment for the enrollee. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare under the circumstances.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered for enrollees who have been diagnosed with Stage IIIB/IV non-small cell lung cancer and meet certain specific criteria. Guardant360 is not covered for diagnosis codes C25.0, C67.4, or D64.9. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 genetic testing provided on August 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora duplex scan of extracranial arteries (93880) provided on October 9, 2019 by doctor.You asked the Plan to waive the copayment forthe duplex scan. You say that you would have refused the scan had you known how much the copayment would be.The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $100 copayment for each Medicare-covered radiological diagnostic service.You have been asked to pay $100 for the duplex scan. A duplex scan falls within the Medicare-covered radiological diagnostic service 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 fora duplex scan of extracranial arteries (93880) provided on October 9, 2019 by doctor.
Appeal type: Lab
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 November 22, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (0042T) provided on September 6, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that the codes listed in A56195 are not medically necessary. We looked at the file and Medicare rules. Per A56195, procedure code 0042T is considered not medically necessary. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the services (0042T) provided on September 6, 2019.