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

We decided that the Plan does not have to pre-approve Opdivo for the enrollee.

You asked the Plan to pre-approve Opdivo. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the use of this drug in your case requires Opdivo will be given as subsequent monotherapy and disease has worsened or spread after prior fluoropyrimidine and platinum-based chemotherapy.

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. Opdivo is not FDA-approved for the enrollee's diagnosis. Approval of Opdivo is for the treatment of unresectable advanced, recurrent, or metastatic esophageal squamous cell carcinoma after prior fluoropyrimidine and platinum-based chemotherapy. This patient has not had prior treatment. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Opdivo. 

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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 21, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 21, 2021, forward. You say that the services at issue are medically necessary. 

The Plan denied your request. The Plan says the services at issue are not medically necessary. 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 pre-approve inpatient psychiatric care from September 21, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 21, 2021, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 21, 2021, as you were not a danger to yourself 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 your condition or for the purpose of diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from September 21, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 21, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) provided on May 19, 2021.

You asked the Plan to pay for the cone beam CT capture and interpretation. You say that this service was necessary because without it the provider would not have had the confidence to effectively treat your tooth. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.

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 cone beam CT capture and interpretation (D0364) provided on May 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from September 1, 2020, to September 12, 2020.

You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with 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 $172 copayment for days 21-100 for SNF care. 

You had a SNF stay from September 1, 2020, to September 12, 2020. The record shows that you had a previous SNF stay for a total of 13 days. Therefore, you are not being charged a copayment for days 14-20 (September 1, 2020, to September 7, 2020). You are responsible to pay a $172 copayment for days 21-24 (September 8, 2020, to September 11, 2020). The total amount you owe is: $172 (copayment) x 4 (SNF days) = $688.

You have been asked to pay the total copayment amount of $688 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 provided from September 1, 2020, to September 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 29, 2021.
You asked the Plan to pay for the comprehensive oral evaluation. You say that you had to find a new dentist because your previous dentist office closed. The Plan denied your request. The Plan says your benefit maximum for this service has been met.
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, comprehensive oral evaluation (D0150) is limited to one every 36 months. The record shows that you received a comprehensive oral evaluation (D0150) on October 29, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve InterStim sacral nerve stimulator (64581, 76000).
You asked the Plan to pre-approve a sacral nerve stimulator. You say that please consider approving this procedure for this enrollee to help improve the quality of her life and prevention of her recent recurrent urinary tract infections. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria due to the diagnosis of stress incontinence.
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 pre-approve a sacral nerve stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has stress incontinence, seizure disorder and multiple CVA's with right hemiparesis. The review has determined that the medical records provided do not meet the requirements listed for Medicare coverage. 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 sacral nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve InterStim sacral nerve stimulator (64581, 76000).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 16, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician visit provided on December 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician visit. You say that you were sent to a hospital that does not accept your insurance. 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 are 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. The record shows the service was not referred by a network provider or rendered in a participating facility. Therefore, we decided that the Plan does not have to pay for the physician visit provided on December 17, 2020 by an out-of-network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640,
87798, 87532) provided December 4, 2020.

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 the documentation does not support the billed services.

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 codes 87486, 87496, 87498, 87541, 87581, 87640, 87798, & 87532 are not supported in the
medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of
service detailed in the records (13, office). 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 (87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided December 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on April 2, 2021.

You asked the Plan to pay for physical therapy services. You say that the records indicate the billed code on this claim is valid. You say that the attached records substantiate the service and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the billed service is not supported.

The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the records do not indicate if the rendering provider was a physical therapist or PTA. A nurse practitioner is not able to bill for the services of a PTA because the nurse practitioner is not a therapist. There is no evidence that the nurse practitioner was on the premises to be able to bill for PT services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on April 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 5, 2020.

You asked the Plan to pay for physician's services. 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 onth 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 physician's services provided on November 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG), continuous recording represented by codes 95720 and 95718 provided from September 15, 2020 to September 16, 2020.
You asked the Plan to pay for codes 95720 and 95718. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 95720 is Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, interpretation and report after each 24-hour period; with video (VEEG). The definition of code 95718 is Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; with video (VEEG). We find that CPT codes 95720 and 95718 are not supported in the medical record. Specifically, codes 95720 and 95718 are time-based codes. The documentation provided for review did not include the duration of time that the video EEG recordings were performed. Based on this information, we decided that Medicare rules for coverage of codes 95720 and 95718 have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG), continuous recording represented by codes 95720 and 95718 provided from September 15, 2020 to September 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97803) provided on March 31, 2021.

You asked the Plan to pay for medical nutrition therapy. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that nutrition therapy services (MNT) is covered for certain beneficiaries who have diabetes or a renal disease. 

We looked at the file and Medicare rules. The record does not show that the enrollee has diabetes or renal disease. Based on this information, we decided that Medicare rules for coverage of medical nutrition therapy have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97803) provided on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RET sequencing and deletion/duplication.
You asked the Plan to pre-approve RET sequencing and deletion/duplication. You say that you would like reconsideration because this testing is necessary to determine if your cancer is genetic and will be passed down
to your family. The Plan denied your request. The Plan says this test will not be used to assist in your management or treatment.
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 pre-approve RET sequencing and deletion/duplication. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that you have a poorly differentiated thyroid cancer. The record indicates that you have decided against further treatment. The record does not indicate that the result of the test will directly impact your treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RET sequencing and deletion/duplication have not been met. Therefore, we decided that the Plan does not have to pre-approve RET sequencing and deletion/duplication.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with a surgeon on May 24, 2021.
You asked the Plan to waive the copayment for the visit with a surgeon. You say that you waited an hour to see the doctor and then found out he was not a vascular surgeon, but a general surgeon. You said that this copayment should be waived because you made the appointment based on the Plan's database showing that this doctor was a vascular surgeon. The Plan denied your request. The Plan says the provider that you saw was a specialist. The Plan says that you were charged this copayment 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 a $35 copayment for visits with a specialist.
You have been asked to pay a $35 copayment for the visit with a surgeon. The visit with a surgeon falls within the visits with a specialist 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 office visit you had with a surgeon on May 24, 2021.
Your complaint about the fact that this provider is listed in the Plan's directory as a Vascular Surgeon is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to perform activities to care for herself. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, the enrollee was at an independent to supervision assist level with functional mobility. She required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept Procedure.

You asked the Plan to pre-approve the Intracept Procedure. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of the Intracept procedure in the setting of chronic low back pain with degenerative disc disease have not been demonstrated in the peer-reviewed literature.

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 pre-approve the Intracept Procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental for the treatment of lower back pain. More research is needed to show safety and efficacy. 

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 Intracept Procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept Procedure.