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

We decided that the Plan has to pre-approve Granix.
You asked the Plan to pre-approve Granix. The Plan denied your request. The Plan says that the drug is not
being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
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 Granix. Our physician reviewer found
that the requested use of Granix is not FDA-approved for the enrollee's diagnosis. However, the use is
supported by research that appears in a CMS-approved medical journal. Treatment of drug-induced
agranulocytosis with granulocyte colony-stimulating factor (G-CSF) is generally associated with shorter
recovery times, less antibiotic use, and shorter length of hospitalization compared with historic or concurrent
controls. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The
documentation does support that the requested drug is safe and effective and otherwise reasonable and
necessary for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Granix have been met. Therefore, we decided that the Plan has to pre-approve
Granix.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on May 21,
2020.
You asked the Plan to pay for the therapeutic procedure. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.
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 97110 is therapeutic procedure, 1 or more areas, each 15
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows
that these services were performed by a physical therapy assistant in the home setting. There is a more
appropriate code to be used for these services provided. Based on this information, we decided that Medicare
rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not
have to pay for the therapeutic procedure coded 97110 provided on May 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pneumatic compressor, segmental home model with
calibrated gradient pressure (CPT code E0652), for the enrollee.

You asked the Plan to pre-approve the DME. You say that a basic pump would not treat the enrollee's condition
above the upper thighs. You state the basic pump was trialed and caused for an increase in trunk measurements
which proves this would be medically unsafe. The Plan denied your request. The Plan says failure of a four week
trial of pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code
E0651) was not provided to the Plan for review.

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 DME. Our physician reviewer
found a trial of a basic pump was trialed which led to increase in truncal measurements so was not prescribed.
Based on the provided documentation, this trial was not documented as having lasted at least four (4) weeks
without benefit to justify the calibrated gradient pressure model compressor. Therefore, the LCD criteria has
not been met.

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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code
E0652), for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on December 1, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the provider was wrong to have you sent to the hospital. You say that the bill should reflect a $0 copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment per Medicare-covered emergency room visit.
The enrollee has been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that ER services were provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on December 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) and second stage implant surgery
(D6011) to replace teeth #6, #11, #21 and #28.

You asked the Plan to pre-approve the implant services. You say that you need to have your two remaining
teeth extracted due to pain, ulcers and infections. You are requesting implants to replace these teeth in order to
use a complete upper denture. The Plan denied your request. The Plan says The natural teeth are in good
condition, and per the Plan's contract, implants will only be approved to support a complete denture in an
enrollee who is missing all of the teeth in the requested arch. You do not meet the criteria.

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. The Plan covers implant services when they are provided to hold a complete denture for members who are completely toothless in an arch.

We looked at the file and Medicare rules. Medical records show that you have teeth remaining in the natural arch where the implants are requested. Based on this information, we decided that the Plan's rules for coverage of the implant services have not been met. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) and second stage implant surgery (D6011) to replace teeth #6, #11, #21 and #28.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided February 8, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you did not know that these types of x-rays were not covered. The Plan denied your request. The Plan says this service is not covered under your 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 the bitewings - four radiographic images (D0274) provided February 8, 2021.
Your complaint about the Plan potentially providing incomplete information in some of the Plan documents 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the certolizumab pegol injection and chemotherapy administration provided on January 19, 2021.
You asked the Plan to waive the coinsurance for the certolizumab pegol injection and chemotherapy administration. You say that you want to appeal the copayment charge. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for outpatient chemotherapy, Part B drugs, and other outpatient services.
You have been asked to pay a total of $490.72 for the certolizumab pegol injection and chemotherapy administration.
Service
Allowed Amount
Coinsurance
Member Liability
Certolizumab Pegol Injection
$2,392.16
20%
$478.43
Chemotherapy Administration
$654.44
20%
$12.29
TOTAL:
$490.72
The certolizumab pegol injection and chemotherapy administration fall within the "Outpatient hospital 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 coinsurance for the certolizumab pegol injection and chemotherapy administration provided on January 19, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 12, 2020 to December 10, 2020.

You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with an incorrect combination of revenue code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 12, 2020 to December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).
You asked the Plan to pre-approve the power seat elevation feature. You say that this power wheelchair is medically needed in the home and will still meet the enrollee's needs without the power elevate. The Plan denied your request. The Plan says this item is not primarily medical in nature and 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2D oral/facial photographic images (D0350 x4) provided on February 25, 2019.

You asked the Plan to pay for 2D oral/facial photographic images. You say that you want the Plan to pay for these services. The Plan denied your request. The Plan says the services at issue are not covered 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 2D oral/facial photographic images (D0350 x4) provided on February 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 28, 2020.

You asked the Plan to pay for the laboratory services. You say that the in-network referring provider referred the pathology for next day results and timely treatment. You say that the service was medically necessary, and the claim should be reprocessed for reimbursement. 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 laboratory services provided by an out-of-network provider on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from November 2, 2020, to December 8, 2020 and billed with DRG 872.

You asked the Plan to pay for inpatient services. You say that DRG 872 is correct. The Plan denied your request. The Plan says DRG 690 is more appropriate.

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 872, septicemia or severe sepsis without mechanical ventilation great than 96 hours without 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 services. Our reviewer says that DRG 872 is not supported in the submitted records. Our physician reviewer found the enrollee was admitted for urinary incontinence, generalized weakness, and loss of appetite. The vitals and laboratory values improved for the duration of the hospital admission.

The sepsis diagnosis was not clinically validated and the documentation does not evidence of this diagnosis.

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 services provided from November 2, 2020, to December 8, 2020 and billed with DRG 872.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for four (4) Keytruda chemotherapy injection visits (J9271) provided on December 24, 2020, to February 25, 2021.

You asked the Plan to waive the coinsurance for chemotherapy injections. You say that you were told there would be no copayment for treatment. You also say you were given misinformation by the Plan. The Plan denied your request. The Plan says the copayment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay a 20% coinsurance for each chemotherapy injection. The allowed amount of the claim for your first visit on December 24, 2020, is $10,169.20, resulting in a coinsurance obligation of $146.15, which is lower than the Plan's contracted amount. The allowed amount of the claim for three visits is $10,129.60, resulting in a coinsurance obligation of $2,025.92 for each visit ($2,025.92 x 3 visits = $6,077.76). You had four visits for chemotherapy injections, for a total cost share of $6,223.91 ($6,077.76 + $146.15 = $6,223.91). The EOC confirms that 20% is the required coinsurance for this service. Chemotherapy injections fall within the Medicare Part B prescription drugs 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 coinsurance for four (4) Keytruda chemotherapy injection visits (J9271) provided on December 24, 2020, to February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a core buildup (D2950), a crown (D2740), and endodontic therapy (D3330) provided on February 2, 2021.

You asked the Plan to pay for a core buildup, a crown, and endodontic therapy. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue are not covered 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 a core buildup (D2950), a crown (D2740), and endodontic therapy (D3330) provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 19, 2021.

You asked the Plan to pay for the therapeutic procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

We find that CPT code 97110 is not supported in the medical record. Specifically, the documentation shows that these services were performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate code to be billed for these services provided. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded 97110 provided on January 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve CT scan. You say that you need this test to establish a treatment plan for you to have a better quality of life. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this test can be performed by an in-network provider.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan to be provided 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 services provided by an out-of-network provider on September 18, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 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 services provided by an out-of-network provider on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on November 27, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. We find that the Guardant360 testing is not supported in the medical record. Specifically, the claim was incorrectly coded with multiple single gene codes as well as unlisted molecular pathology codes. There is a more specific code to be billed for these services provided. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care (99509).
You asked the Plan to pre-approve a home visit. You say that the services are necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
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. Based on this information, we decided that Medicare rules for coverage of a home visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a home visit for assistance with activities of daily living and personal care (99509).