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

We decided that the Plan does not have to pre-approve Pembrolizumab.
You asked the Plan to pre-approve Pembrolizumab. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 pre-approve Pembrolizumab. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the enrollee's tumor has a PDL1 of 0% and single agent treatment would not be indicated. Combination with pemetrexed is for maintenance therapy after platinum-based therapy and would not be indicated. In addition, results for estimated glomerular filtration rate (EGFR) and anaplastic lymphoma kinase (ALK) are not provided. The service is not reasonable or 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 Pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical drug (CPT code J2997) and home-hemodialysis (CPT code 90935) provided to the enrollee from August 27, 2020, through August 31, 2020.
You asked the Plan to waive the coinsurance for the services. You say that your spouse was not at the hospital within the date range. The Plan denied your request. The Plan says the claims were processed accordingly with the enrollee's 2020 EOC 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).
Review of the file show that the enrollee received medical drugs and home-hemodialysis from August 27, 2020, through August 31, 2020. The enrollee was asked to pay 10% coinsurance for the Part B covered prescription drugs and 20% coinsurance for home-hemodialysis. The enrollee's 2020 EOC states that enrollees must pay 10% of the cost for Part B covered prescription drugs and enrollees must pay 20% of the cost for Medicare-covered renal dialysis. 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 coinsurance for the medical drug (CPT code J2997) and home-hemodialysis (CPT code 90935) provided to the enrollee from August 27, 2020, through August 31, 2020.
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. You say that the IRF admission is medically necessary. The Plan
denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 based on the medical records provided the complexity of your nursing, medical and
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to
rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the office visit. You say that you should be able to see this provider because you feel that this doctor would be the best choice for your mental health counseling. 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 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 and is a Licensed Mental Health Counselor (LMHC). Medicare does not cover services rendered by a LMHC. 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 the outpatient office visit (99213) 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 pre-approve a percutaneous peripheral nerve stimulator (PNS).
You asked the Plan to pre-approve a PNS. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that PNS trials are covered when specific criteria are met. 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 a PNS. Our reviewer says that the services are not medically necessary. Our physician reviewer found there is no psychological evaluation submitted for review. There has been no trial of the PNS that demonstrates greater than 50% pain reduction. Therefore, the criteria are not met, and the request is deemed, at this time, to be medically unreasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PNS have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous peripheral nerve stimulator (PNS).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.
You asked the Plan to pre-approve Supartz. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that various polymers of hyaluronic acid are covered when specific criteria are met. 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 Supartz. Our reviewer says that the
services are not medically necessary. Our physician reviewer found there is no documentation of conservative therapy such as weight loss, physical therapy, home exercise program or bracing. Therefore, the request does not meet the criteria and the request is considered not medically reasonable or necessary at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medication Retacrit (Q5106).
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says that the off-label use of this drug for the enrollee's condition is not medically accepted per Medicare rules and isn't covered based upon available information.
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 this medication. Our reviewer says that your request does not meet Medicare criteria for coverage of this medication. Our physician reviewer found that the requested use of this medication has not been approved for the enrollee's diagnosis in this case. Additionally, the requested use has not been supported by one of the major drug compendium or by clinical research that appears in a Centers for Medicare and Medicare Services (CMS) approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve the medication Retacrit (Q5106).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services provided on November 30, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the radiology services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 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 radiology services provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator.
You asked the Plan to pre-approve osteogenesis stimulator, electrical, non-invasive, spinal applications (E0748). You say that you are scheduled for a spinal fusion and want this device for healing. The Plan denied your request. The Plan says an osteogenesis stimulator is not standard treatment for the spinal stenosis.
The Plan must follow Medicare rules. The rules say that an osteogenesis stimulator is covered for failed spinal fusion, multilevel spinal fusion, or previously failed spinal fusion at same site.
In this case, the file does not show a history of a multilevel or failed spinal fusion. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 3, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed. The Plan denied your request. The Plan says no prior authorization was 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 the office visit provided on February 3, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.
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 that in this case, the enrollee was admitted with ventilator dependent respiratory failure and developed intraabdominal infection. The case file indicates that the enrollee is receiving acute care services that have not been denied. The case file does not indicate that the enrollee requires acute care services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 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-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a LTACH admission.
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 that in this case, the enrollee was admitted for an infected sacral decubitus ulcer. The case file indicates that the enrollee is receiving acute care services that have not been denied. The case file does not indicate that the enrollee requires acute care services that he is not currently receiving that would be available at the LTACH facility. The elements of the coverage rule are not satisfied. The requested service cannot be recommended.
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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed (CPT code 55866-22) and laparoscopy, surgical; with bilateral total pelvic lymphadenectomy (CPT code 38571-22) provided to the enrollee on October 8, 2020.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 services. Our physician reviewer found CPT code 55866-22 - Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed billed to the health plan for the services provided on October 8, 2020, does not meet criteria for billing or reimbursement. The medical records provided do not include sufficient documentation to support the modifier 22, indicate increased procedural service, therefore, this service cannot be verified. 

CPT code 38571-22 - Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy billed to the health plan for services provided on October 8, 2020, does not meet criteria for billing or reimbursement. The medical records provided do not include sufficient documentation to support the modifier 22, indicating increased procedural service, therefore, this service cannot be verified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed (CPT code 55866-22) and laparoscopy, surgical; with bilateral total pelvic lymphadenectomy (CPT code 38571-22) provided to the enrollee on October 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received January 25, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you did not order the ambulance and do not think you should have to pay. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $175 copayment for Medicare-covered one-way ground ambulance transportation.
You have been asked to pay a $175 copayment for the ambulance transportation. The service received falls within the Medicare-covered one-way ground ambulance transportation benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0429, A0425) received January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on January 12, 2021.

You asked the Plan to pay for the office visit. You say that the medical records support the service was medically necessary. You say that the center treats all patients with excellent care and should be reimbursed for the service rendered. The Plan denied your request. The Plan says authorization was not obtained and in-network providers were available.

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 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 office visit provided by an out-of-network provider on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).

You asked the Plan to pre-approve the POV. You say that you cannot walk and need a scooter to get around. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. Under Medicare guidelines, your request is not medically necessary because your records show you need evaluation of your home to be sure it can accommodate a power scooter. Your current weight of 375 pounds exceeds the capacity of the vehicle you are requesting. Therefore, we decided that the Plan does not have to pre-approve POV, group 1 standard, patient weight capacity up to and including 300 pounds (CPT code K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 17, 2021, to February 25, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer 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 had network providers available who could have provided 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 lab work provided on February 17, 2021, to February 25, 2021 by an out of network (OON) provider.