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

We decided that the Plan has to pre-approve Vitamin B-12 Cyanocobalamin and Dexamethasone Sodium Phosphate. We decided that the Plan does not have to pre-approve Fosaprepitant and Palonosetron HCL.
You asked the Plan to pre-approve Dexamethasone Sodium Phosphate, Fosaprepitant, Vitamin B-12 Cyanocobalamin, and Palonosetron HCL. You say that you would like the plan to reconsider their denial. The Plan says that the requested drugs are not medically necessary.
We decided that the Plan has to pre-approve Vitamin B-12 Cyanocobalamin and Dexamethasone Sodium Phosphate.
Our doctor says that the documentation supports that the requested drug, Vitamin B-12 Cyanocobalamin is medically reasonable and necessary. Our doctor found that the FDA label for Alimta states that Vitamin B12 should be given 1 week before starting Alimta and every 3 cycles. The submitted documents indicate that the enrollee will be receiving his 6th cycle which falls in the FDA recommendation. Therefore, the use of Vitamin B12 is medically reasonable and necessary and safe and effective for the enrollee at this time. The NCCN antiemesis guideline, page AE-7 lists Dexamethasone as part of treatment for low risk agents. Therefore, the use of Dexamethasone is medically reasonable and necessary and is safe and effective for the enrollee.
Therefore, we decided that the Plan has to pre-approve Vitamin B-12 Cyanocobalamin and Dexamethasone Sodium Phosphate.
We also decided that the Plan does not have to pre-approve Fosaprepitant and Palonosetron HCL.
Our doctor says that the requested drugs, Fosaprepitant and Palonosetron HCL are not medically reasonable or necessary. Our doctor found that the enrollee has non-small cell lung cancer and is receiving chemotherapy with Alimta and Avastin. The NCCN Guidelines Version 2.2020 Antiemesis page AE-3 lists Alimta as having low risk and Avastin as having minimal risk of vomiting. Therefore, the chemotherapy regimen is considered low risk for emesis. The NCCN guideline page AE-7 lists recommended combinations of drugs for antiemesis with low risk regimens. Palonosetron and Fosaprepitant are not listed for use with low risk regimens. Palonosetron and Fosaprepitant are not FDA approved or compendium supported for use with low risk chemotherapy regimens. They are not listed as not indicated, not supported or not recommended in any of the compendia.
Therefore, we decided that the Plan does not have to pre-approve Fosaprepitant and Palonosetron HCL.
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 the assembly and operation of a pump (99190) provided on April 29, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on April 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral exam (D0140) provided February 18, 2020.You asked the Plan to pay forthe dental services. You say that the first dentisttold you needed 2 teeth extracted because of decay. You went to this provider for a second opinion. You are on a fixed income.The Plan denied your request. The Plan says this service exceeds the benefit frequency limitation.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. This service is allowed once a year. The records show that this service was provided on January 6, 2020.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 forlimited oral exam (D0140)provided February 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 4, 2019 through January 10, 2019.You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because this infusion code is not for durable medical equipment and was not delivered to the member's home.The Plan denied your request. The Plan says S codes are not payable by Original Medicare.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 CPT code S9328 is not supported in the record. Specifically, per the physician fee schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 4, 2019 through January 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on October 29, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered. 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 by an out-of-network provider on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the enrollee was medically stable with no evidence of need for supervision by the physician or needs acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.
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 pre-approve SNF care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found the enrollee does not have complex wound care, a need for new enteral feedings or other SNF level need. It is not medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis, periodic oral evaluation, and bitewings provided on February 12, 2020 by an OON provider.
You asked the Plan to pay for the prophylaxis, periodic oral evaluation, and bitewings. You say that you have been going to this dentist for 30 years. The Plan denied your request. The Plan says the treating provider is OON. The Plan also says that you do not have OON benefits for the dental supplement.
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 prophylaxis, periodic oral evaluation, and bitewings provided on February 12, 2020 by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management provided on December 2, 2019.You asked the Plan to pay for the hospital discharge day management. You say that the service was performed out of necessity to best treat the enrollee. You also say that the information you have provided warrants a reversal of the denial.The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.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.Therefore, we decided that the Plan does not have to pay for the hospital discharge day management provided on December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea portable gaseous oxygen system to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea portable gaseous oxygen system. You say that standard size tanks are too heavy for you.The Plan denied your request. The Plan says that it is not medically necessary to receive this item with this 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-approvea portable gaseous oxygen system to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.You asked the Plan to pre-approve a powered upper extremity range of motion assist device (L8702). You say that this device would restore function to the dysfunctional arm and the ability to perform activities of daily living.The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of your health problem.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary, and are experimental and investigational, are not covered.  We looked at the file and Medicare rules. There is insufficient medical record information submitted to show this orthosis would be preferred or more effective than the traditional upper orthosis types that are covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a powered upper extremity range of motion assist device (L8702) have not been met.Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay fortherapy services (97140, 97763, 99205, 99213) for the treatment of  temporomandibular joint (TMJ) syndrome.You asked the Plan to pay fortherapy services. You say that you were told this could be covered.The Plan denied your request. The Plan says that services for TMJ are not covered.The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only when the condition or symptom is medical in nature. The treatment must also be medically reasonable and necessary. 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 therapy services. Our reviewer says that the services at issue meet criteria for coverage. Our physician reviewer found the documentation supports that the services at issue are primarily focused on a medical condition and not services to treat structures supporting the teeth. The jaw pain is centered in the joint, particularly the right side, and does not specifically involve the teeth. The documentation supports the need for the services provided as to treat the condition of the jaw, with positive results noted on reexamination by the provider. Orthotic usage and physical therapy are commonly used conservative therapies that often yield positive results. The positive results supports the suggestion that muscular dysfunction was a the core of the TM joint issues.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapy services have been met.Therefore, we decided that the Plan has to pay fortherapy services (97140, 97763, 99205, 99213) for the treatment of  temporomandibular joint (TMJ) syndrome.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the specialist office visit , the corneal curvature measurement, and the diagnostic imaging of optic nerve provided on February 11, 2020.You asked the Plan to waive the copayments for the specialist office visit, the corneal curvature measurement, and the diagnostic imaging of optic nerve. You say that you were under the impression that these services were required as a part of the procedure before the surgery. 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 a $45 copayment for each in-network covered specialist office visit and a $100 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a $45 copayment for the specialist office visit and a $100 copayment for the corneal curvature measurement and the diagnostic imaging of optic nerve. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The corneal curvature measurement and the diagnostic imaging of optic nerve 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 copayments for the specialist office visit, the corneal curvature measurement, and the diagnostic imaging of optic nerve provided on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on December 2, 2019 and January 27, 2020.
You asked the Plan to waive the copayments for specialist visits. You say that these were follow-up visits and you were told that you would not owe a copayment. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15 copayment for specialist services. You received specialist services on December 2, 2019 and January 27, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay a $15 copayment per each visit. The total amount you owe is: $30. You have been asked to pay the total copayment amount of $30 for specialist visits. Specialist visits fall within the physician/practitioner services, including doctor's office visits 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 copayments for specialist visits provided on December 2, 2019 and January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on January 21, 2020.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 nurse practitioner services provided on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable treadmill.
You asked the Plan to pre-approve a portable treadmill. You say that you have had surgery and need to walk in
a safe environment inside your home. The Plan denied your request. The Plan says treadmills are not covered
by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Home exercise/
physical therapy equipment that can be obtained without a prescription is considered to be an over the counter
supply, is not considered DME, and is therefore ineligible for coverage. Therefore, we decided that the Plan
does not have to pre-approve a portable treadmill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve over the counter (OTC) benefits.You asked the Plan to pre-approve OTC benefits. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and OTC benefits is an OTC item.Therefore, we decided that the Plan does not have to pre-approve over the counter (OTC) benefits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on January 14, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that the TC and PC of diagnostic services are separately paid if furnished in different payment localities.We looked at the file and Medicare rules. The file shows that the laboratory services were billed with modifier -26 for the PC. The file does not support that the PC is separately payable for these services. 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 pay forthe laboratory services rendered on January 14, 2020.