Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
You asked the Plan to pre-approve a semi-electric hospital bed. You say that you would like reconsideration because you fall out of bed and bed rails have not helped. The Plan denied your request. The Plan says there is no documentation that you need the head of your bed raised above 30 degrees, that you cannot use pillows to raise your head, that you have significant limitations of bed mobility or need to move frequent for pain management or that you have pressure skin wounds due to limited bed mobility.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the documentation does not clearly reveal that you have pain or a condition that has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. Our physician reviewer found you do not require the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. The documentation does not support a need for a frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 18, 2020.

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 testing is 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, a pulmonary screening panel, 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 rendered on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on June 3, 2021.
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you are a senior and cannot afford 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drugs on June 3, 2021. The total allowed amount is $2,067.60 and 20% of that is $413.52.
You have been asked to pay the total coinsurance amount of $413.52 for Medicare Part B drugs. Medicare Part B drugs fall within the Medicare Part B prescription drugs 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 Medicare Part B drugs provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on April 5, 2021.

You asked the Plan to waive the copayment for vision care. You say that you received a routine eye exam and should not be responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each eye exam to diagnose and treat diseases and conditions of the eye, and a $0 copayment for routine eye exams for vision care. 

The record shows that you received vision care beyond a routine eye exam on April 5, 2021. Therefore, you are responsible to pay the $40 copayment. 

You have been asked to pay a $40 copayment for vision care. Vision care falls within the vision 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 vision care provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit and the coinsurance for a ketorolac tromethamine injection on May 1, 2021.
You asked the Plan to waive the copayment for an urgent care visit and the coinsurance for a ketorolac tromethamine injection. You say that you received the Coronavirus (Covid-19) vaccine and had a reaction to it two days later. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment for each urgent care facility/clinic visit. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare-covered Part B drugs. You have been asked to pay a $40 copayment for an urgent care visit. Urgent care visits fall within the Urgently Needed Services benefit category. You have also been asked to pay a total of $.52 coinsurance, which is 20% of the allowed amount for a ketorolac tromethamine injection ($2.60 allowed amount x 20% coinsurance = $.52). A ketorolac tromethamine injection falls within the Medicare Part B Prescription Drugs benefit category. The records show that this urgent care visit and this ketorolac tromethamine injection was not related to a diagnosis of Covid-19. 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 an urgent care visit and the coinsurance for a ketorolac tromethamine injection on May 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299).

You asked the Plan to pre-approve Opdivo. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met in this case.

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 the requested drug is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of metastatic esophageal cancer with human epidermal growth factor receptor 2 (HER2) overexpression. The record indicates that the requested drug will be administered with the chemotherapy regimen FOLFIRI. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.

No literature from Medicare approved cancer journals were submitted for review. The elements of the coverage criteria 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 Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve the acute inpatient hospital care. You say that you were admitted for diverticulitis. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

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 pre-approve the 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 recent documentation does not suggest a special circumstance or clinical presentation that would suggest you require hospital services that would cross 2 midnights for this lower risk surgery. Our reviewer also found that an observation status would be more appropriate. 

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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says Vertiflex is investigational and experimental, and the member is not receiving this device as part of a Medicare-covered clinical trial.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental and more research is needed to show its 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 Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal bone growth (osteogenesis) stimulator.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a bone growth stimulator is covered 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 these services. Our reviewer says that
the criteria for coverage are not met. Our physician reviewer found the records show that you had spinal fusion
surgery on July 6, 2021. The records do not show that there is a history of past failed fusion surgeries or
multilevel fusion surgery. The criteria for coverage are not met; therefore, the spinal bone growth stimulator is
not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a spinal bone growth (osteogenesis) stimulator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two osseous surgeries (D4260 x2), three bone replacement grafts (D4263 x3), and therapeutic parenteral drug (D9610).

You asked the Plan to pre-approve the osseous surgeries, bone replacement grafts, and therapeutic parenteral drug. You say that you need to have an osseous surgery and bone replacement graft, but the Plan does not cover these procedures. The Plan denied your request. The Plan says these services are not covered under your benefit package.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two osseous surgeries (D4260 x2), three bone replacement grafts (D4263 x3), and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation and intraoral x-ray provided on May 21, 2021.

You asked the Plan to pay for the limited oral evaluation and intraoral x-ray. You say that all the dentist did was look at the tooth, take an x-ray and tell you a root canal was necessary. You say that claim should be covered in full as a follow up to previous treatment. The Plan denied your request. The Plan says the services are not covered 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 limited oral evaluation and intraoral x-ray provided on May 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for home health services provided from February 3, 2021, to February 25, 2021.

You asked the Plan to waive the deductible for home health services. 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. Your contract with the Plan says that there is a $400 deductible which applies to home health agency care. 

You received home health services from February 3, 2021, to February 25, 2021. The record shows that you had paid $0 toward the $400 deductible prior to receiving the services. Therefore, you are responsible to pay the total deductible amount of $400.

The item or service you asked the Plan to waive the deductible for falls within the benefit category home health agency care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which applies to home health agency care. This cost sharing is a contractual obligation that had not been met at the time home health services were received on February 3, 2021 to February 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for home health services provided from February 3, 2021, to February 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99307) provided on March 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the facility is an inpatient facility and should be processed as an in-network place of service. Services rendered were referred by a participating provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 subsequent nursing facility care (99307) provided on March 11, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the urology office visit and the chemotherapy drugs you received on April 6, 2021.

You asked the Plan to waive the cost sharing for the urology visit and the chemotherapy drugs. You say that you were not aware of this denial until you received the bill. You believe that this was denied because your urologist didn't get authorization. The Plan denied your request. The Plan says these services were not denied, but you were charged the appropriate cost sharing for this office visit and these drugs.

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 drugs and a $25 copayment for services with a specialist.

You have been asked to pay 20% coinsurance for the chemotherapy drugs and a $25 copayment for the urology visit. This means that you have been asked to pay the correct amounts 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 cost sharing for the urology office visit and the chemotherapy drugs you received on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ozempic.
You asked the Plan to pre-approve Ozempic. You say that you would like the Plan to reconsider their denial.
The Plan denied your request. The Plan says Ozempic is not covered under the enrollee's Medicare Part B
benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ozempic.
Benefits for Ozempic may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan represented by code 70450 provided on May 15, 2021.
You asked the Plan to pay for code 70450. 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 as billed.
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 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 represented by code 70450 provided on May 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PT in the home (S9131).

You asked the Plan to pre-approve the PT in the home. You say that you broke your leg and had a rod inserted. You also say that you had PT services, but additional service was denied. The Plan denied your request. The Plan says you can continue your therapy with non-skilled help.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 PT in the home. Our reviewer says that the PT in the home is not medically necessary or reasonable. Our physician reviewer found you do not have documented skilled therapy needs. 

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 PT in the home have not been met. Therefore, we decided that the Plan does not have to pre-approve the PT in the home (S9131).