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

We decided that the Plan does not have to pre-approve use of filgrastim SNDZ (Zarxio).
You asked the Plan to pre-approve Zarxio. You say that the enrollee has non-small cell lung cancer and this would be a valuable treatment option. The Plan denied your request. The Plan says the denial of authorization for Zarxio is correct, because this drug is not supported with treatment that is low risk.
The Plan follows Medicare rules. Medicare rules state that filgrastim may be used under certain clinical conditions.
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 Zarxio. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Zarxio. Our physician reviewer found carboplatin/pemetrexed with pembrolizumab is associated with a low risk of neutropenic fever. There is no evidence that other factors are increasing risk or that the enrollee has had neutropenic fever. This use of Zarxio is not medically reasonable or 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 Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve use of filgrastim SNDZ (Zarxio).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physical therapy provided from March 01, 2021 through March 29, 2021.
You asked the Plan to waive the deductible for physical therapy. You say that the services were provided in the same manner as a previously claim that paid at a rate of $102. You say that the claims should be processed at the same rate and an additional check should be issued. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to outpatient rehabilitation services. This cost sharing is a contractual obligation that had not been met at the time physical therapy was received on March 1, 2021 to March 29, 2021. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided from March 01, 2021 through March 29, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on March 6 to March 7, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the requested level of care was a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested level of care have not been met.
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 fell at home and presented to the emergency department. The enrollee was diagnosed with pelvic fractures and peritoneal hematoma. There was no hemodynamic instability noted or acute laboratory findings requiring inpatient level care at the time of admission. 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 March 6 to March 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on May 4, 2021.

You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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. In this case, we have confirmed that code 70450 for the computed tomography 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 coded 70450 provided on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on April 29, 2021.

You asked the Plan to pay for the chest x-ray. You say that this is not a duplicate charge. The Plan denied your request. The Plan says an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. 

We find that CPT code 71046 was billed with code 32555. Code 71046 is separately payable. However, the code was not billed with an appropriate modifier. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on April 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary due to severe sepsis. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 20, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit (99214). You say that the Plan should pay this claim. The Plan denied your request. The Plan says prior authorization was not obtained as required.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 20, 2021 by an out-of-network provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided on February 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. 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 area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the ultrasound provided on February 8, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need to be admitted into an IRF for continued therapies and monitoring of your blood sugars. You also say that your medication dosage is still being adjusted and you do not feel ready to return home. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the inflatable prosthesis provided on May 10, 2021. 
 
You asked the Plan to pay for the services provided. You say that you were told that the service was covered. 
The Plan denied your request. The Plan says that the service is not a covered benefit on your plan. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
We looked at the file and the rules. The services at issue were provided by a contract provider. The file does 
not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this 
means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay 
for the inflatable prosthesis provided on May 10, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography scans to be provided by an out-of-network provider.
You asked the Plan to pre-approve computed tomography, thorax (71260) and computed tomography, abdomen and pelvis (74177). You say that you need these CT scans done very three months and they have always been approved previously. The Plan denied your request. The Plan says the requested facility is out-of-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve computed tomography scans to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) provided on May 13, 2021.
You asked the Plan to pay for the bone replacement graft. You say that you are aware that the Plan provides a $1,000 allowance per year for dental services. You also say that you believe the services should be covered even if the rendering provider was not in-network. The Plan denied your request. The Plan says this service is not covered. The Plan also says that there were no contacted from you to the Plan in regard to your dental benefit for the provided services.
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 bone replacement graft for ridge preservation (D7953) provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that the provider is in-network. 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 area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the office visit provided on January 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided on July 2, 
2020. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 80307 and G0480 are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of 
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in an office setting, place of service 11.

 Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0480 provided 
on July 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on March 23, 2021.
You asked the Plan to pay for the therapy 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 as billed.
The Plan must follow Medicare rules. Medicare rules 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 have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services provided on March 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain fused to high noble metal crown (D2750).

You asked the Plan to pre-approve the porcelain fused to high noble metal crown. You say that the enrollee has a tooth infection and needs a crown to prevent fracture after treatment. The Plan denied your request. The Plan says this service is not covered under the enrollee's 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 pre-approve the porcelain fused to high noble metal crown (D2750).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for venography (75820) provided on September 24, 2020.
You asked the Plan to pay for the venography. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says payment for CPT code 75820 is included in the
payment for 37238.
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 asked our coder 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 venography. Our reviewer says that CPT code 75820 59
does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does
not support the use of modifier 59 which is a distinct procedure which should be used to distinguish a different
session or patient encounter, different procedure or surgery, or a different anatomical site or separate injury.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the venography have not been met. Specifically, CPT code 75820 has a bundled
relationship with CPT code 37238 and cannot be paid as billed. Our coder found that the documentation does
not support the use of modifier 59 to indicate that this procedure was separate and distinct. Therefore, we
decided that the Plan does not have to pay for venography (75820) provided on September 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zirabev.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has peritoneal carcinomatosis. She has been treated with FOLFOX for occult primary disease suggestive of gastrointestinal/biliary involvement. Zirabev is not FDA-approved for the treatment of occult primary in combination with FOLFOX, nor is it approved for gastroesophageal or biliary primary disease. The use is not supported by the medical literature or major drug compendia. Zirabev is not considered safe and effective or reasonable and medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Zirabev