Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic audiological evaluation, fitting/orientation/checking of hearing aid and hearing aidsprovided on February 11, 2020.You asked the Plan to pay for the hearing services. The Plan denied your request. The Plan says you must use the Plan's hearing aid vendor.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids onlyWe looked at the file and the Plan's rules. The file shows that the hearing services were not provided by the Plan's hearing benefit vendor. Based on this information, we decided that the Plan's rules for coverage of the hearing services have not been met. Therefore, we decided that the Plan does not have to pay for a diagnostic audiological evaluation, fitting/orientation/checking of hearing aid and hearing aids providedon February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 23, 2020 by an out of network (OON) provider.You asked the Plan to pay fordrug testing. You say that authorization was on file for this claim.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 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 urgentcare 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service atissue. 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 forthe medical services provided on July 23, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092 and R0075) provided on April 1, 2020.
You asked the Plan to pay for the transportation and set up of a portable x-ray. You say that you would like reconsideration because this is a covered benefit. The Plan denied your request. The Plan says separate payment is not made for x-ray or EKG equipment transport for a member in an inpatient institution or a skilled nursing facility.
The Plan must follow Medicare rules. Medicare rules say that if the patient is in a Part A SNF stay, the transportation and set up costs are subject to consolidated billing and not separately billable to Medicare Part B. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation and set up of a portable x-ray have not been met. The record indicates that this member was in a Part A SNF stay on the billed date of service. Payment for the transportation and set up of the portable x-ray is subject to consolidated billing. Therefore, we decided that the Plan does not have to pay for the transportation and set up of a portable x-ray (Q0092 and R0075) provided on April 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ipilimumab and Nivolmab.
You asked the Plan to pre-approve Ipilimumab and Nivolmab. You say that the requested Ipilimumab and
Nivolmab are medically necessary. The Plan denied your request. The Plan says the requested Ipilimumab and
Nivolmab are 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 Ipilimumab and Nivolmab. Our
reviewer says that the requested Ipilimumab and Nivolmab are not medically necessary. Our physician
reviewer found the enrollee is with a diagnosis of metastatic pancreatic small cell carcinoma. It is noted that the
enrollee is not an ideal candidate for cytotoxic chemotherapy due to recurrent infectious complications. The
enrollee's oncologist writes that high-grade neuroendocrine cancer is treated according to treatment small cell
lung cancer regimens.
The requested use of Ipilimumab and Nivolumab are 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. This reviewer did not find any supporting citations for the use of Ipilimumab and Nivolumab
for the treatment of metastatic pancreatic small cell carcinoma in a PubMed search.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ipilimumab and Nivolmab have not been met. Therefore, we decided that the
Plan does not have to pre-approve Ipilimumab and Nivolmab.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe laboratory services coded as 85025, 83036, 80061, 80053, 81001, 36415 provided August 21, 2020.You asked the Plan to waive the copayment forthe laboratory services. You say that the office was closed where you usually get your lab  done so you were referred to this facility. They didn't tell you that it will cost you $15.If you had known you wouldn't go.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the plan benefits.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 $15 for lab services completed in an outpatient hospital .You have been asked to pay $15 for the laboratory services. The laboratory services fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe laboratory services coded as 85025, 83036, 80061, 80053, 81001, 36415 provided August 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedeep sedation/general anesthesia for dental services.You asked the Planto pre-approvethe anesthesia. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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 benefitin excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedeep sedation/general anesthesia for dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 3, 2020 by an out of network (OON)provider.You asked the Plan to pay foroffice visit. You say that the provider took actions on behalf of the enrollee and should be paid.The Plan denied your request. The Plan says the denial of payment for this service is correct, because thisprovider is out-of-network with the Plan 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 has network providers available who can provide the items/services at issuein this appeal. 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 forthe medical services provided on September 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided July 14, 2020.
You asked the Plan to pay for the orthosis. You say that you have attached the supporting documentation. Please reprocess the claim. The Plan denied your request. The Plan says there was no prior authorization and this was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this brace is used for back pain. The notes from the enrollee's provider do not mention back pain. There are no reported abnormal physical exam findings. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.
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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided July 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on August 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that your clinical documentation is clear and demonstrates medical necessity. The physician provided medically necessary services in good faith. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 items/services at issue in this appeal. 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 outpatient office visit (99213) provided on August 31, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvecontinued inpatient psychiatric care beyond January 12, 2021.You asked the Planto pre-approvethe continued inpatient care. You say that ongoing care in the inpatient setting is necessary.The Plandenied your request. The Plansaysthe enrollee can be managed in a less restrictive setting.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 continued inpatient care. Our reviewer says that the documentation does not support the continued need of psychiatric care at the inpatient level. Our physician reviewer found this 84-year-old male was admitted to the acute inpatient psychiatric hospitalization on January 5, 2021 with Major Neurocognitive Disorder with Behavioral Disturbance. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates inquestion as noted above as he was not a danger to himself or others and did not have any illusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis.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 continued inpatient care have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued inpatient psychiatric care beyond January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endosteal implant (D6010) provided on May 15, 2020.
You asked the Plan to pay for the endosteal implant. You say that your dentist advised you that this an implant
was the best option for you. The Plan denied your request. The Plan says this service is not a covered benefit
under your dental 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 pay for the
endosteal implant (D6010) provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 22, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forsurgical services. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan 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 has network providers available who can provide the items/services at issue in this appeal. 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 forthe medical services provided on July 22, 2020, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy (31641, J2704, J1100, J2405) provided on
January 8, 2020.
You asked the Plan to pay for the bronchoscopy. You say that the service was medically necessary. The Plan
denied your request. The Plan says the provider was out-of-network and no authorization was provided.
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 items/services at issue in this appeal. 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 bronchoscopy (31641, J2704, J1100, J2405)
provided on January 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory testing provided on August 12, 2020.You asked the Plan to waive the copayment forlab test. You say that this test was ordered by your primary care provider as part of aroutine physical, so it should have been covered in full.The Plan denied your request. The Plan says the copayment amount 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 $12 copayment for lab test. You have been asked to pay $12 copayment for lab test. Lab test falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forlaboratory testing provided on August 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is needed to provide adequate maintenance of your condition. The Plan denied your request. The Plan says there is a lack of medical necessity.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have COPD. You have reportedly been on BiPAP at home, and reportedly continue to have CO2 retention. However, there is no compliance data. There is no documentation of CO2 retention on a blood gas. It does not appear that you have tried BiPAP in the AVAPS mode, which is the mode requested for the ventilator. Medicare does not cover a ventilator when used as BiPAP. A home ventilator is not medically 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D7953, D4266, D7921) provided August 13,
2020.
You asked the Plan to pay for the dental services. You say that these services were medically necessary and
should be covered. The Plan denied your request. The Plan says the dental services at issue are not covered
services under your dental 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 pay for dental
services (D7953, D4266, D7921) provided August 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe CardioMEMS HF system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthe clinical value of this device has not been established and, therefore, the request is not indicated at this time.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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this circumstance therapy change based on data obtained from a CardioMEMs device has been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into question the results. Therefore,the efficacy of the CardioMEMS device is uncertain at this time according to leading authorities and not recommended in current guidelines for the treatment of heart failure.  Medicare coverage criteria are not met since the device should still be considered experimental or investigational.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 system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe CardioMEMS HF system for the enrollee.