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

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you need transportation for your appointment. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 12 one-way trips per calendar year is not covered by the Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that after 12 one-way trips have been covered by the Plan the Plan's routine transportation benefit will be exhausted. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 17, 2021.
You asked the Plan to pay for periodontal maintenance. You say that you thought this service would be covered. The Plan denied your request. The Plan says the service at issue 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 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 periodontal maintenance (D4910) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nail debridement provided by an out-of-network provider on November 10, 2020.
You asked the Plan to pay for the nail debridement. You say that the doctor was not responsible to get authorization since the member was in a nursing facility. You say that the claim should be reprocessed and the provider reimbursed for services rendered. 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 nail debridement provided by an out-of-network provider on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 00400 provided on September 16, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 00400 is anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified.

We find that CPT code 00400 is not supported in the medical record. Specifically, two or more diagnosis codes that were billed with this code are mismatched. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (bilateral) code is available. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00400 provided on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided a participating provider on December 8, 2020, to December 30, 2020.

You asked the Plan to waive the copayment for physical therapy. You say that you already met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $40 copayment for outpatient rehabilitation services/in-network/physical therapy. 

You have been asked to pay a $40 copayment for physical therapy. At the time of these services, your out-of-pocket maximum had not been met; therefore, the correct copayment has been applied. Physical therapy falls within the outpatient rehabilitation services/in-network/physical therapy 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 physical therapy provided by a participating provider on December 8, 2020, to December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for a reline of complete lower denture (D5751) and a reline of complete upper denture (D5750) provided on January 21, 2021.
You asked the Plan to pay an additional amount for a reline of complete lower denture and a reline of complete upper denture. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the service is a covered benefit, but you have exceeded the frequency limit of one procedure code per calendar year at 25% when services are rendered by an out-of-network provider.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a reline of complete lower denture, and a reline of complete upper denture have not been met. Specifically, the record shows that you had exceeded the frequency limit. Therefore, we decided that the Plan does not have to pay an additional amount for a reline of complete lower denture (D5751) and a reline of complete upper denture (D5750) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 19, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the service was rendered as part of your yearly checkup. You say that there is no copayment per your plan benefits. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 per visit to a specialist. You have been asked to pay a $30 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show a non-preventive service was billed. 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 office visit provided on January 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Enhertu (J9358).
You asked the Plan to pre-approve Enhertu. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for treatment with Enhertu have not been met.
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 Enhertu. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the requested use of Enhertu is 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 Medicare-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 Enhertu have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Enhertu (J9358).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) computed tomography, cervical spine (72125) provided December 8, 2020.

You asked the Plan to pay for the CT scans. You say that you believe CPT codes 72125 and 70450 were denied for incorrect reasons. The Plan denied your request. The Plan says the charges show incorrect date of service or patient name.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

In this case, we find that CPT codes 70450 and 72125 are not supported in the medical record. Specifically, the medical records submitted do not clearly indicate that the CT scans were performed on the billed date of service. In addition, the documentation does not support this procedure was repeated by the billing physician. The records do not support a separate interpretation and report was completed. The claim history supports a different billing provider completed the interpretation and report. The records show that the Plan made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the CT scans have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) head or brain (70450) computed tomography, cervical spine (72125) provided December 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 21, 2020.

You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications.

Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129 and L36523 to support their denial. However, LCD L36139, L36129 and L36523 are not valid for the provider's billing state of Texas. Therefore, we are unable to use LCD L36139, L36129 and L36523 to substantiate our decision.

While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 21, 2020.
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 it is felt that LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet LTACH coverage criteria.

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 she is 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.

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 the home health services provided to the enrollee from July 1, 2020 to July 27, 2020.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the codes billed are invalid for home health care. In addition, the claim is missing the Medicare identification for the provider along with the treatment authorization code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 1, 2020 to July 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Blenrep.
You asked the Plan to pre-approve Blenrep. You say that the enrollee has failed Zometa, Velcade, Darzalex, and Pomylast. The Plan denied your request. The Plan says the denial of authorization for Blenrep is correct, because Blenrep is used for adults who have received 4 prior lines of therapy including an anti-CD38 monoclonal antibody which the enrollee has not yet received.
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 Blenrep. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Blenrep. Our physician reviewer found Blenrep is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Blenrep is approved after at least 4 prior lines of therapy, but the enrollee has only had 2. The requested use of Blenrep is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-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 Blenrep have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Blenrep.
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 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 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level
of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: 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 you would like reconsideration because the LTACH admission is medically necessary. 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 the medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 

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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
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 you do not have complex nursing or rehabilitation needs.
There is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different 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: 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 the enrollee's 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee 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.