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

We decided that the Plan does not have to pre-approve Keytruda (J9271) with a regimen of 400mg every 3 weeks for 3 doses, followed by 400mg every 6 weeks for 4 doses.
You asked the Plan to pre-approve the Keytruda regimen. You say that the enrollee is considered ineligible for Carboplatin and Cisplatin, per guidelines. You also say that the enrollee should be treated with Keytruda. The Plan denied your request. The Plan says the requested regimen exceeds the recommended standard dosing.
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 the Keytruda regimen. Our reviewer says that the requested Keytruda regimen is not medically necessary. Our physician reviewer found the standard dosing for Keytruda is typically 200 mg once every 3 weeks, or 400 mg once every 6 weeks; continue until disease progression, unacceptable toxicity, or (in patients without disease progression) for up to 24 months. The reviewer found that the proposed dosing is not standard. Therefore, the reviewer found that the requested dosing regimen 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 the Keytruda regimen have not been met. Specifically, the requested dosing regimen is not the standard. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271) with a regimen of 400mg every 3 weeks for 3 doses, followed by 400mg every 6 weeks for 4 doses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve CPAP supplies. You say that these items are medically necessary. The Plan denied your request. The Plan says that this service is available by a provider in your network.
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 continuous positive airway pressure (CPAP) supplies to be provided by an out of network (OON) provider.
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 March 21, 2020.
You asked the Plan to pay for the laboratory services. You say that the physician supports treatment at the level of care billed. You say that the facility requests processing the claim for approval of payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 March 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (11102, 11103) provided by an out-of-network provider on March 25, 2021.
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 (11102, 11103) provided by an out-of-network provider on March 25, 2021.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care. The enrollee does not require services at the LTACH that are not available at the present setting where she is currently receiving 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 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: 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 the enrollee meets LTACH requirements and would benefit from LTACH services. The Plan denied your request. The Plan says the enrollee is currently receiving the appropriate care, and an LTACH is not medically necessary. Records indicate that the estimated length of care will be less than 25 days, and the complexity of care required does not necessitate an LTACH. Once the enrollee is medically stable, the necessary care can be reviewed for and be safely provided in another 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care.
There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate in this case.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that this equipment is medically
necessary to help your swelling. The Plan denied your request. The Plan says this equipment is statutorily not
covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
noncovered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric level of care services provided September 26, 2020 to September 29, 2020.
You asked the Plan to pay for the inpatient services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the submitted bill does not match authorization
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 pay for the inpatient services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was cooperative and compliant with medication and reported doing well. 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. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, 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 enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 26, 2020. 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 inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric level of care services provided September 26, 2020 to September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inflatable lift for the enrollee.
You asked the Plan to pre-approve an inflatable lift. You say that the enrollee needs this in case he falls. The Plan denied your request. The Plan says that this is not primarily medical in nature.
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. Therefore, we decided that the Plan does not have to pre-approve an inflatable lift for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two pontics (D6245 x2) and two retainer crowns (D6740 x2).
You asked the Plan to pre-approve the pontics and retainer crown. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 pre-approve two pontics (D6245 x2) and two retainer crowns (D6740 x2).
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the ultrasound. We decided that the Plan does not have to waive the copayment for the ultrasound.
You asked the Plan to waive the copayment for the ultrasound. You say that you had a mammogram and was not expecting any charges. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the copayment for the ultrasound.
The Plan says you must pay a $30 copayment for the ultrasound based on the x-ray benefit. An ultrasound is not considered an x-ray. Therefore, we decided the Plan has to reduce the copayment for the ultrasound from $30 to $10.
We also decided that the Plan does not have to waive the copayment for the ultrasound.
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 $10 copayment for other outpatient diagnostic tests. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you further for out of network urgent care services provided on January 16, 2021.
You asked the Plan to reimburse you for overpayment for urgent care services. You say that you believe the Plan owes this reimbursement. The Plan denied your request. The Plan states you paid $125 for urgent care services with a non-contract provider on January 16, 2021. However, the Plan can only reimburse the Medicare-allowed amount less any applicable copayment. The Medicare allowed amount for this service is $76.07. Your copayment is $55 leaving a balance of $21.07, which was paid to you by the Plan. Any additional overpayment should be obtained from the non-contract provider as they applied non-Medicare rates to your care. 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 $55 copayment for urgent care. Plans are only allowed to reimburse you for Medicare allowed rates for services rendered.
You have been reimbursed the full amount allowed by Medicare, per your Plan contract. The Plan is not responsible for the amount owed by the non-plan provider which was charged above the Medicare allowable. Therefore, we decided that the Plan does not have to reimburse you further for out of network urgent care services provided on January 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay from October 1, 2020, to October 31, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you contracted COVID-19 at the facility and feel that you should not be responsible for the charges. 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 $0 copayment for days 1-20, and a $178 copayment for days 21-57 for SNF care. You had a SNF stay from October 1, 2020, to October 31, 2020. The record shows that you had a previous SNF stay for a total of 3 days. Therefore, you are not being charged a copayment for days 4-20 (October 1, 2020, to October 17, 2020). You are responsible to pay a $178 copayment for days 21-34 (October 18, 2020, to October 31, 2020). The total amount you owe is: $178 (copayment) x 14 (SNF days) = $2,492. You have been asked to pay the total copayment amount of $2,492 for a SNF stay. A SNF stay falls within the SNF care 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 a SNF stay from October 1, 2020, to October 31, 2020.
We note your complaint that you contracted COVID-19 at the facility. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services provided on August 25, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that a referral was not received from the PCP.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the services by a contract provider and provided the services at a participating facility. The file does not show that the plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the services provided on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this device is
medically necessary for the condition. The Plan denied your request. The Plan says the coverage criteria for
this device have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit (99336) rendered by the OON provider on
March 11, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the rest home visit (99336) rendered
by the OON provider on March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on February 24, 2021.
You asked the Plan to pay for the limited evaluation. You say that this service was necessary and should be covered. The Plan denied your request. The Plan says limited oral evaluations are not covered by your dental 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 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 limited oral evaluation (D0140) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit received on March 2, 2021.
You asked the Plan to pay for the office visit. You say that you feel this service would be covered. The Plan denied your request. The Plan says that the services received is not a covered benefit.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were provided the office visit by a contract provider. The file does not show that the Plan provided notice that the office visit would not be covered. Under Medicare rules, this means the office visit is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the office visit received on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 10, 2019 and billed under codes 95870, 95938 and 95955.
You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says each of these codes were denied due to issues with the place of service codes billed and the status of the enrollee at the time of treatment. The billed place of service (POS) 15 is not supported. The records show the enrollee was an inpatient at the time services were provided. The Plan also states these codes cannot be paid for services in a facility setting. Payment for this service is included in payment to the facility and not separately reimbursable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case each of the codes billed caused a claim error due to an incorrect POS code, not being able to be paid separately and not being able to be applied to a facility claim. Medicare billing criteria are not met. The Plan states a corrected claim would be required. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 10, 2019 and billed under codes 95870, 95938 and 95955.