Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 28, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the care that was provided was medically necessary. The Plan denied your request. The Plan says the documentation does not support an inpatient level of care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then 74-year-old male enrollee who presented pre-operatively to the acute care hospital on April 28, 2021, at 05:53. He underwent his planned knee arthroplasty with no peri-or post-operative complications noted. He was deemed medically necessary for discharge to home at 14:36 hours on the same day. His stay did not cross over any midnights and his total length of stay, including the surgery was approximately 8 and a half hours. The review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mental health care provided to the enrollee from August 4, 2021, to September 1, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 mental health care provided to the enrollee from August 4, 2021, to September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.
You asked the Plan to pre-approve Opdivo. You say that Opdivo to be used with Faslodex is medically necessary. The Plan denied your request. The Plan says the Nivolumab/Opdivo and Bevacizumab-awwb/Mvasi treatment is considered investigational as a treatment option for enrollee's metastatic ovarian cancer. The Plan also says that this means the treatment is still being developed or it has not been shown to improve health outcomes for the metastatic ovarian cancer.
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 Opdivo. Our reviewer says that Opdivo is not medically reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Opdivo is not Food and Drug Administration (FDA) approved for the enrollee's diagnosis as a combination or as individual agents. Our reviewer also found that the use of Opdivo is not supported by one of the major drug compendia or by clinical research that appears in a 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation and repeat procedure (76881 and 76881-76) provided June 10, 2021.

You asked the Plan to waive the copayment for the ultrasound and repeat ultrasound. You say that the ultrasound copayment should be $20. The Plan denied your request. The Plan says the cost-sharing was 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). The enrollee's contract with the Plan clearly says that the enrollee must pay a $150 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in a free-standing facility.

The enrollee has been asked to pay a total of $130.50 for the ultrasound and repeat ultrasound. The ultrasound and repeat ultrasound fall within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The ultrasound is considered a radiological diagnostic service. This means that the enrollee has been asked to pay less than or equal to the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation and repeat procedure (76881 and 76881-76) provided June 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.

You asked the Plan to pre-approve a Freestyle Libre CGM and supplies. 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. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) and supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that the medication is 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 Aranesp. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review indicates that the documentation does not support that the Aranesp is medically reasonable and necessary for the enrollee. The documentation does not support that the Aranesp is safe and effective for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of head or brain (70450) provided on September 2, 2021.  You asked the Plan to pay for the CT scan services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not billed with this claim as required by Medicare rules.  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 have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of head or brain (70450) provided on September 2, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 28, 2021.  

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 99285 (ER visit) and 99291 (critical care services). Code 99285 is a column II code with a modifier indicator of 1 when billed with column I code 99291. Code 99285 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the emergency room (ER) services rendered on April 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve epidural steroid injections.  

You asked the Plan to pre-approve epidural steroid injections. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.  

The Plan follows Medicare rules. Medicare rules say that ESI will be considered medically reasonable and necessary 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 epidural steroid injections. Our reviewer says that the services are medically necessary. Our physician reviewer found the request meets the LCD criteria and is medically reasonable and 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 epidural steroid injections have been met. Therefore, we decided that the Plan has to pre-approve epidural steroid injections.   

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: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (80307) provided on June 21, 2021.

You asked the Plan to pay for drug testing. You say that this code was last billed more than a year ago. The Plan denied your request. The Plan says that the frequency relationship criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say that it is not appropriate to report more than twelve (12) presumptive urine drug testing (UDT) (code 80305, 80306, or 80307) services per calendar year. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Although the Plan states that the testing at issue was denied due to frequency, the Plan has not provided any documentation showing when the enrollee previously received this testing. Therefore, we decided that the Plan has to pay for drug testing (80307) provided on June 21, 2021.

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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided on March 19, 2021.

You asked the Plan to pay for the diagnostic service. You say that the service should be covered. The Plan denied your request. The Plan says the ultrasonic guidance is not necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the diagnostic service. Our reviewer says that the requested ultrasonic guidance is not considered medically reasonable and necessary in this case. Our physician reviewer found the ultrasound guidance is not supported by current evidence for trigger point injections to the back area as tactile manual guidance is typically sufficient. The reviewer also found that there was no indication this case was an exception. Therefore, the reviewer found that the ultrasound guidance will be considered not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Specifically, the file shows that the ultrasound guidance is not supported by current evidence for trigger point injections to the back area as tactile manual guidance is typically sufficient. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided on March 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit.

You asked the Plan to pre-approve a Freestyle Libre 14-day sensor kit. 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. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

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 Freestyle Libre 14-day sensor kit have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day sensor kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital care (99223) provided July 9, 2021.  You asked the Plan to pay for the hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says this code is not separately 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.        We find that CPT code 99223 is not supported in the medical record. Specifically, the billed code is part of the Global Surgery Package of code 36556 which was billed by the same provider on the same date of service. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99223) provided July 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (0013M) provided July 12, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this procedure is non-covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for code 0013M, CxBladder testing.  We looked at the file and Medicare rules. The procedure at issue is non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0013M) provided July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit (99204) provided on  March 12, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  

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 $25 copayment for a specialist telehealth/office visit.   

You have been asked to pay a $25 copayment for the specialist telehealth visit provided. 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 (99204) provided on March 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from March 9, 2021, through March 20, 2021.  

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.  

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 $350 copayment per day, for days 1-5 and a $0 copayment per day, for days 6-90 for inpatient hospital care.   

You have been asked to pay $1,750 ($350 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from March 9, 2021, through March 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided January 19, 2021.  You asked the Plan to pay for the periodontal maintenance. You say that the provider messed up your insurance and you don't feel you should be responsible for the cost. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 periodontal maintenance (D4910) provided January 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for a radiologic examination provided on October 30, 2020.  You asked the Plan to pay for a radiologic examination. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  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 a radiologic examination provided on October 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the injection, Ocrelizumab, provided on July 21, 2021.  You asked the Plan to waive the coinsurance for the injection, Ocrelizumab. You say that you cannot afford the cost share. The Plan denied your request. The Plan says the cost share was 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 20% coinsurance for Medicare Part B prescription drugs.   You have been asked to pay 20% coinsurance for Medicare Part B prescription drugs for the injection, Ocrelizumab. This service falls within the Outpatient hospital services 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 coinsurance for the injection, Ocrelizumab, provided on July 21, 2021.