Persius/hicric huggingface dataset:
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 the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.
The enrollee's care needs, as a practical matter, can be provided at a lower level of care.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tresiba Flex.

You asked the Plan to pre-approve Tresiba Flex. You say that the drug being requested is medically necessary and appropriate. The Plan denied your request. The Plan says the requested medication falls under Part D coverage. The Plan says that the enrollee does not have a Part D pharmacy benefit administered by them.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered 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 Tresiba Flex.

Benefits for Tresiba Flex 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 urography (74420) provided July 1, 2021.
You asked the Plan to pay for the diagnostic services. You say that you used the TC modifier because ou are
the facility and for the facility claim TC is billable. The 26 modifier is billable for professional claim and the
professional claim already paid under the 26 modifier to the doctor. The Plan denied your request. The Plan
says the procedure code is inconsistent with the modifier used or a required modifier is missing. This claim line
is being disallowed because of an invalid or missing modifier code.
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 find that CPT code 77420 is not supported in the medical record. Specifically, per Medicare
guidelines, procedure code 74420 describes a diagnostic procedure that requires a professional component
modifier in point of service 24. When billing these services in an inpatient hospital, outpatient hospital, or
skilled nursing facility, only the professional component should be billed by the physician. Billing of the
technical component is inappropriate by the physician as the facility should be responsible for submitting it.
Modifiers 26 and TC can be used with these codes. Based on this information, we decided that Medicare rules
for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to
pay for urography (74420) provided July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0012M) provided May 5, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for codes
0012M and 0013M for CxBladder.
We looked at the file and Medicare rules. This service is not covered under Medicare rules. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services (0012M) provided May 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

You asked the Plan to pre-approve Keytruda, Carboplatin, Paclitaxel, Dexamethasone and Diphenhydramine.
You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this
drug/regimen is not being prescribed for a medically accepted indication.
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 Keytruda, Carboplatin, Paclitaxel,
Dexamethasone and Diphenhydramine. Our reviewer says that Keytruda, Carboplatin, Paclitaxel,
Dexamethasone and Diphenhydramine are not medically reasonable and necessary for the enrollee. Keytruda,
Carboplatin, Paclitaxel, Dexamethasone and Diphenhydramine are not FDA-approved for the enrollee's
diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a
Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of Keytruda, Carboplatin, Paclitaxel, Dexamethasone
and Diphenhydramine.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda, Carboplatin, Paclitaxel, Dexamethasone and Diphenhydramine have
not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Carboplatin,
Paclitaxel, Dexamethasone and Diphenhydramine for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (PCD).
You asked the Plan to pre-approve the PCD. You say that you would like reconsideration because the requested equipment is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of the requested PCD.
The Plan follows Medicare rules. Medicare rules say that PCDs are 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 the PCD. Our reviewer says that you do not require the device for the treatment of chronic venous insufficiency with venous stasis ulcers. Our physician reviewer found you have not had a sufficient four-week trial of conservative therapy demonstrating failed response to treatment (including elevation, exercise, and compression). 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 PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compression device (PCD).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.
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 PET scans are covered only when they are
medically 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 was diagnosed with
prostate cancer in 2019 and chose to maintain surveillance. He has not undergone initial treatment for the
prostate cancer. He has stage III prostate cancer and rising prostate specific antigen (PSA). A computed
tomography (CT) scan on May 4, 2021 did not demonstrate metastases. On September 30, 2021 it is
documented that the enrollee did not want to pursue treatment. The records do not support that the PET meets
the criteria for coverage. The services are not reasonable or medically necessary at this time.
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 positron emission tomography (PET) scan.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the colonoscopy with biopsy (45380) provided on June 24, 2021.
You asked the Plan to pay for the colonoscopy and waive the cost-share. You say that this service was
medically necessary and should be covered. The Plan denied your request. The Plan says that you have
exceeded the number of colonoscopy screenings you may have in a year. You are also responsible for your
cost-sharing for this service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules also 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.
The record indicates that you received a screening colonoscopy in May of 2021, which could not be completed
due to excessive bleeding. Polyps were also found at this time. You were instructed to have a diagnostic
colonoscopy at a later date to remove and biopsy the polyp. The Plan denied these services, stating that you
have already had a screening colonoscopy for this year and have exceeded your benefit for this preventative
service. The Plan also says a coinsurance or copayment amount applies to this service and is asking you to pay
$215.19 for this service.
The colonoscopy provided in this case, billed with procedure code 45380, is a diagnostic colonoscopy and is
classified as an outpatient surgical procedure. This service was not billed as a screening colonoscopy. You
were referred for the diagnostic colonoscopy by a contract provider. The file does not show that the Plan
provided notice that the colonoscopy would not be covered. In addition, the Plan has not made reasonable and
diligent efforts to gather and forward to us information regarding their decision to deny your request. Under
Medicare rules, this means the colonoscopy is considered approved by the Plan. Therefore, we decided that the
Plan has to pay for the colonoscopy with biopsy (45380) provided on June 24, 2021.
The rules also say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information.
Your contract with the Plan says that enrollees must pay a $0 copayment for outpatient surgery.
The Plan says you must pay $215.19 for the colonoscopy with biopsy. Based on the Plan contract, however,
you cannot be asked to pay more than a $0 copayment for outpatient surgery services. Therefore, we decided
that the Plan has to waive the copayment for the colonoscopy with biopsy (45380) provided on June 24, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atorvastatin Calcium for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered
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 Atorvastatin Calcium for
the enrollee.

Benefits for this drug 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: 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 enrollee currently meets LTACH admission criteria. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 and does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on November 5, 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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on November 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation. You say that you are asking the
Plan to approve additional rides as you have upcoming appointments and have no means of transportation. The
Plan denied your request. The Plan says you have exhausted the maximum benefit of 24 one-way trips per year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 24 trips per year.
We looked at your request, the records in the case file, and the rules. The records show that you have used 24
one-way transportation trips this year. Based on this information, we decided that you have exhausted the Plan
maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to
provide coverage for additional routine transportation trips (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 17, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for advance care planning (99497) provided on November 9,
2020 by an out-of-network (OON) provider.
You asked the Plan to pay for advance care planning. You say that kindly review and reprocess the appeal
towards payment. 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 advance care planning (99497) provided on
November 9, 2020 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 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 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 IRF admission is not medically necessary. Documentation does not support the
necessity. While the enrollee may benefit from physical therapy (PT) and occupational therapy (OT), her
rehabilitation needs can be safely met in an alternate and low intensity setting such as in an skilled nursing
facility (SNF).
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 waive the coinsurance for the inpatient admission and services
provided from March 17, 2021, to March 18, 2021.

You asked the Plan to waive the coinsurance for the inpatient care. You say that these services were necessary
and should have been covered as outpatient care. The Plan denied your request. The Plan says you have been
asked to pay less than your contractually required 20% coinsurance for these services. Because this was
calculated incorrectly due to Plan error, your cost-share will remain as it has been billed. Inpatient care requires
20% coinsurance.

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 inpatient hospital care.

You have been asked to pay less than 20% coinsurance for the inpatient care. The services you received were
approved and found to be medically necessary at this level of care. This means that you have been asked to pay
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
coinsurance for the inpatient admission and services provided from March 17, 2021, to March 18, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a semi-electric hospital bed for the enrollee.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical information submitted on appeal does not demonstrate the enrollee's need for frequent changes in body position.
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 the bed. Our reviewer says that the requested bed is medically reasonable and necessary. Our physician reviewer found that in this case, the enrollee suffers from a large hiatal hernia that makes eating and drinking difficult. The enrollee has gastro-esophageal reflux disease, and is at a higher aspiration risk, and must keep the head of the bed at 30 degrees. Additionally, she has to make frequent changes to body positions. 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 bed have been met. Therefore, we decided that the Plan has to pre-approve a semi-electric hospital bed for the enrollee.
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.