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

We decided that the Plan does not have to pre-approve Aloxi, Carboplatin, Paclitaxel, Dexamethasone, Imfinzi,
Famotidine, and Diphenhydramine.
You asked the Plan to pre-approve Aloxi, Carboplatin, Paclitaxel, Dexamethasone, Imfinzi, Famotidine, and
Diphenhydramine. You say that the medication is necessary. The Plan denied your request. The Plan says since
the member is enrolled in a clinical trial, the requested drugs are deemed a routine cost.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve Aloxi, Carboplatin, Paclitaxel, Dexamethasone, Imfinzi,
Famotidine, and Diphenhydramine as part of a clinical trial. The Plan does not cover routine costs associated
with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Aloxi,
Carboplatin, Paclitaxel, Dexamethasone, Imfinzi, Famotidine, and Diphenhydramine.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for skilled nursing facility (SNF) services you received from November 1, 2020, to November 17, 2020.
You asked the Plan to reduce the copayment for the SNF services. You say that you were only in this facility for 28 days, so you should have a lower copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $0 copayment for days 1-20, and a $100 copayment per day for days 21-100 for skilled nursing facility services.
Records show that you were in a SNF for 6 days from October 9, 2020, to October 15, 2020. You were not charged a copayment for these 6 days. You were then admitted to another the SNF stay from October 21, 2020, to October 31, 2020, for 10 days. You were not charged a copayment for these 10 days. You remained in the SNF from November 1, 2020, to November 17, 2020. You were not charged a copayment for the first 4 days of this stay. For the remaining 13 days, you were charged a $100 copayment per day, for a total of $1300. Within this benefit period, you spent 33 days in the SNF. You were not charged a copayment for the first 20 days. 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 reduce the copayment for skilled nursing facility (SNF) services you received from November 1, 2020, to November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 8, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 the lab services provided on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cancer screening test (81407, 81408, 81432,
81479, 81295, 81298, 81317, 81403, 81404, 81405, and 81406) provided on November 20, 2020.
You asked the Plan to pay for the hereditary cancer screening test. You say that you would like reconsideration
because this testing was medically necessary. The Plan denied your request. The Plan says Medicare does not
cover this testing for screening purposes.
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 hereditary cancer screening test. Our
reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no microsatellite instability or mismatch repair testing on the tumor provided
to help guide decision making regarding genetic testing. The patient was not under the age of 50 at diagnosis.
Criteria for genetic testing was not meet.
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 hereditary cancer screening test have not been met. Therefore, we decided
that the Plan does not have to pay for the hereditary cancer screening test (81407, 81408, 81432, 81479, 81295,
81298, 81317, 81403, 81404, 81405, and 81406) provided on November 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulances services (A0428, A0425)
provided on March 31, 2021.
You asked the Plan to pay for non-emergent ambulances services. You say that the services at issue were a
medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the
services at issue have not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 non-emergent ambulances services. Our
reviewer says that the services at issue were not medically reasonable and necessary in this case. Our physician
reviewer found that there was no documentation of the enrollee being bed bound or that the enrollee is unsafe
to ride in a wheelchair. The documentation did not support that other means of transport (such as stretcher van,
wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee.
The documentation did not support that the enrollee needed the expertise, services, and lifesaving and lifesustaining
equipment that only a fully equipped ambulance can provide for safe transport. The documentation
did not support that the ambulance transport on March 31, 2021, was medically reasonable and necessary 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 non-emergent ambulances services have not been met. Therefore, we decided
that the Plan does not have to pay for non-emergent ambulances services (A0428, A0425) provided on March
31, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of September 23, 2021 the member did not require any skilled nursing or rehabilitation services on a daily basis. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care. The member's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services you received on August 26, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that this copayment should be waived because this transport could have been avoided. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this transport ($175) is less than your copayment obligation, you are responsible for the full allowed 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 $245 copayment per one-way trip for ambulance services. You have been asked to pay a $245 copayment per one-way trip for the ambulance services. This copayment applies regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance services you received on August 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller
(E2377), expandable controller harness (E2313) and a power seat elevation feature (E2300).
You asked the Plan to pre-approve these items. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your upper limb strength and function are adequate for you to be able to
control the power options using their own switches.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare rules also say that a power seat elevation feature is non-covered because it
is not primarily medical in nature.
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 these items. Our reviewer says that an
electronic connection, expandable controller and expandable controller harness not considered medically
reasonable and necessary in this case. Records indicate you have left upper extremity gross motor and fine
motor skills within functional limits thus indicating adequate strength and function to operate the wheelchair's
power options with their own switches. Our physician reviewer found that your condition does not meet criteria
for an electronic connection, expandable controller and expandable controller harness.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not
have to pre-approve an electronic connection (E2311), expandable controller (E2377), expandable controller
harness (E2313) and a power seat elevation feature (E2300).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on July 9, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the OON drug testing. You say that this testing was medically necessary and should be paid. The Plan denied your request. The Plan says these services were not referred by a network provider and not authorized. Drug testing is available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing provided on July 9, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI to be rendered by a tertiary level provider.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because you have been seeing this provider for years and they have access to all of your records. The Plan denied your request. The Plan says the submitted documentation does not show that you require a tertiary level of care.
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 MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that it is not medically necessary for the member to receive tertiary level of care at the requested provider. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI to be rendered by a tertiary level provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for manual wheelchair accessory, pneumatic propulsion tire (E2211) manual wheelchair accessory, tube for pneumatic propulsion tire (E2212) miscellaneous DME supply or accessory (A9999) purchased April 27, 2021.
You asked the Plan to pay for the wheelchair accessories. You say that the tire on your power wheelchair split and this is your only means of transportation. Getting tires quickly was a must. The Plan denied your request. The Plan says this provider does not participate with Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for manual wheelchair accessory, pneumatic propulsion tire (E2211) manual wheelchair accessory, tube for pneumatic propulsion tire (E2212) miscellaneous DME supply or accessory (A9999) purchased April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) for teeth # 2 and 3 provided on January 19, 2021.
You asked the Plan to pay for the dental services. You say that the core build up for teeth # 2 and 3 are medically necessary. You say that the teeth have less than 50% healthy tooth structure remaining. You also say that the enrollee will have crowns completed in the near future. The Plan denied your request. The Plan says core build up is covered when performed in conjunction with a crown. The Plan says that crowns were not performed. The Plan also says that core build up is not covered when it is use as a filling.
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 and core build up is listed as covered,
the services were not provided in conjunction with crowns. Additionally, the record does not indicate that the
enrollee has an appointment set for the crowns to be placed. Therefore, we decided that the Plan does not have
to pay for the core build up (D2950) for teeth # 2 and 3 provided on January 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
You asked the Plan to pre-approve a mastectomy sleeve. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a mastectomy sleeve (L8010) is denied as noncovered, since it does not meet the definition of a prosthesis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a mastectomy sleeve have not been met. Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves are 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 RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee had two lumbar radiofrequency ablation procedures, namely one on February 8, 2021 and one on March 8, 2021. The record indicates that the enrollee has had two procedures in the current 12 month rolling period in the same region. The elements of the coverage criteria as not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 23, 2021, to February 28, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's leg improved on the hospital's regimen. The Plan denied your request. The Plan says that the enrollee could have been observed for a period of time, then re-evaluated and discharged with oral antibiotics and outpatient follow up.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department with right lower extremity pain and swelling for over one week. The enrollee had a weeping wound on the anterior right shin. The record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 23, 2021, to February 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6534.
You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered as it does not meet the statutory definition of a dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6534 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 A6534.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services billed with HIPPS code KDXF1 x 5 and provided on July 10, 2020, through July 15, 2020.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says documentation is needed of the assessment of the member's usual performance used to support this coding.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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 SNF services. Our reviewer says that the documentation does not support the HIPPS code of KDXF1 x 5. Our reviewer found the record does not support that the enrollee's usual performance was documented at the time the service was provided. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services billed with HIPPS code KDXF1 x 5 and provided on July 10, 2020, through July 15, 2020.