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

We decided that the Plan does not have to pre-approve Nuplazid.
You asked the Plan to pre-approve Nuplazid. You say that this drug is a medical necessity and appropriate for
the enrollee's treatment. You also say that the enrollee has improved since starting to take Nuplazid. The Plan
denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Nuplazid.
Benefits for Nuplazid 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for measurement of blood oxygen level (94760) provided on February 1, 2020.
You asked the Plan to pay for the measurement of blood oxygen level. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is included in another service provided at the same time and is not allowed separately.
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 code 94760 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 94760 has a status indicator of T. This means that CPT code 94760 is only paid if there are no other services payable under the Physician Fee Schedule billed on the same date by the same provider. The record indicates that CPT code 99213 has been approved for the same date of service by the same provider, therefore payment for CPT code 94760 is bundled into the payment for the approved physician service, 99213. Based on this information, we decided that Medicare rules for coverage of the measurement of blood oxygen level have not been met. Therefore, we decided that the Plan does not have to pay for measurement of blood oxygen level (94760) provided on February 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for laboratory test. You say that the enrollee meets the Medicare criteria for this test. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 has network providers available who can provide 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 medical services provided on February 25, 2020 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.
You asked the Plan to pre-approve Rituxan. You say that this is medically necessary. The Plan denied your request. The Plan says that original Medicare covers routine costs associated with clinical trials.
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 Rituxan 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 Rituxan for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the professional component (PC) of a diagnostic mammogram (CPT
77066) provided on December 6, 2019.
You asked the Plan to pay for the professional component of the diagnostic mammogram. You say that the
records provided support the procedure was performed by your provider. You say that the claim denied as a
duplicate in error. The Plan denied your request. The Plan says that payment for the procedure in dispute as
made on the facility claim, per Medicare guidelines.
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. The rules say that payment for diagnostic mammography, bilateral in the Hospital Outpatient Setting
(Revenue code 401) is the lesser of charge, or TC of MPFS for code 77066.
The records show, and Medicare rules support, that the payment for 77066 billed on a hospital claim under
revenue code 0401 is only the technical component of the code. The Plan has not provided us information to
support their decision to deny your request. There is no basis on which to deny payment of the professional
component of the code to the interpreting physician because there is no evidence of the hospital or any other
provider having been paid for the professional component. Therefore, we decided that the Plan has to pay for
the professional component (PC) of a diagnostic mammogram (CPT 77066) provided on December 6, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA) of the right hip.You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says this is not medically necessary.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 RFA. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure.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 RFA have not been met.Therefore, we decided that the Plan does not have to pre-approve cooled radiofrequency ablation (RFA) of the right hip.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided on January 28, 2020.
You asked the Plan to pay for the physical therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim must be submitted to your primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the physical therapy services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided on January 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 20, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no valid referral for this service.
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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on August 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4KScore genetic testing provided to the enrollee on
December 11, 2019.
You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your
request. The Plan says the test became commercially available in March 2014 and has not been approved by the
FDA.
The Plan must follow Medicare rules. Medicare rules say that the 4KScore test is not a covered test.
The test at issue in this case is not covered and not approved by the FDA at the time of service. Based on this
information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we
decided that the Plan does not have to pre-approve 4KScore genetic testing provided to the enrollee on
December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 20, 2020.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room during the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 24, 2020 by an out of network (OON) provider.You asked the Plan to pay for office visit. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring physician is also out-of-network with the Plan.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 has network providers available who can provide 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 medical services provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on December 6, 2019 by an out of network (OON) provider.You asked the Plan to pay for physician services. You say that you provide these services in good faith of reimbursement.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were provided at the member's non-participating living facility.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 has network providers available who can provide 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 physician services provided on December 6, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency department visit (99285) provided on February 12, 2020.You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration because this claim was denied as a duplicate in error.The Plan denied your request. The Plan says the documentation submitted does not support an additional unit of CPT code 99285.The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. In this case, we have confirmed that code the emergency department visit has been previously paid for a physician in the same group with the same specialty on the same date of service. 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 an emergency department visit (99285) provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Stimwave trial for the genicular nerves.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic knee pain and is status post intrathecal pump. The requested stimwave trial of the genicular nerve is considered an experimental/investigational procedure. There are no published trials in peer-reviewed literature supporting the use of Stimwave for the genicular nerves. The services are therefore 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 Stimwave trial for the genicular nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on March 5, 2020 by an out of network (OON) provider.You asked the Plan to pay for wound care. You say that these services were medically necessary.The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that 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 has network providers available who can provide 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 wound care provided on March 5,2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Palonosetron for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the proposed chemotherapy regime is considered low risk emetogenic

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Topotecan carries a low emetogenic potential and bevacizumab (avastin) a very low emetogenic potential. Palonsetron is indicated for moderate and highly emetogenic agents. The service is reasonable and 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Palonosetron for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botox is only covered for certain indications. 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 Botox injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee does have migraine headaches, but the provided medical records do not document any trial of medications such as anticonvulsants, antidepressants, or antihypertensives that are typically used for migraine prevention. Therefore, the documentation does not support that it is medically necessary and reasonable for this enrollee to have Botox injections as requested. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (CPT 85060) provided to the enrollee on June
13, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says CPT code 85060 may not be paid if furnished to hospital outpatients or non-hospital patients.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 85060 is "Blood smear, peripheral, interpretation by
physician with written report."
We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not coded correctly. Our coding reviewer found per Medicare guidelines,
85060 (Blood smear, peripheral, interpretation by physician with written report) unless the service is for a
hospital inpatient (place of service 21). Hospital outpatients or non-patients is that payment for the underlying
clinical laboratory test is made to the hospital.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for lab services (CPT 85060) provided to the enrollee on June 13, 2019.