Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz.
You asked the Plan to pre-approve Supartz. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Supartz. Our reviewer says that Supartz is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee is noted to have osteoarthritis. There is no evidence that the enrollee is allergic to or intolerant of the plan's other required forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee. Therefore, the requested Supartz is not shown to be currently medically necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular cytogenetics services coded 88374 provided on October 30, 2019.
You asked the Plan to pay for the molecular cytogenetics services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are a duplicate.
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 88374 is molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells. We find that CPT code 88374 is not supported in the medical record. Specifically, this code was reported twice for the same date of service, once with modifier 26 and once without a modifier. It is inappropriate to report a procedure both as a global service and as the technical or professional components. Based on this information, we decided that Medicare rules for coverage of the molecular cytogenetics services have not been met. Therefore, we decided that the Plan does not have to pay for the molecular cytogenetics services coded 88374 provided on October 30, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 73610 provided on November 11, 2019.
You asked the Plan to pay for the x-ray. 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 a covered benefit.
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 73610 is radiologic examination, ankle; complete, minimum of 3 views. We find that CPT code 73610 is not supported in the medical record. Specifically, this code was billed with an outpatient place of service. The date of service falls between the admission and discharge date of inpatient confinement. Any service performed during an inpatient confinement is considered to be performed in an inpatient setting. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray coded 73610 provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve caregiver services (S5100).
You asked the Plan to pre-approve caregiver services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says custodial care is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Custodial care is not covered. We looked at the file and Medicare rules. The file shows you are requesting caregiver services, also known as custodial care. Custodial care includes care that helps people with activities of daily living, like walking, getting in and out of bed, bathing, dressing, eating, personal hygiene, and supervision of special diets and medications. Custodial care and caregiver services are not covered under your Medicare benefit. Therefore, we decided that the Plan does not have to pre-approve caregiver services (S5100).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that the doctor's office should check your insurance. The Plan denied your request. The Plan says the service was performed by a doctor who is not in your 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 services at issue in this appeal. 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 the medical services provided on November 13, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral nerve stimulation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says sacral nerve stimulation is considered experimental, investigational, and unproven for the treatment of chronic constipation.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not support that Interstim would be needed or beneficial for this patient. Interstim is not indicated for constipation and an Interstim trial did not confirm any significant improvement in voiding parameters. Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacral nerve stimulation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan of the chest
You asked the Plan to pre-approve the LDCT. You say that the records provided support the need for the requested CT scan. The Plan denied your request. The Plan says the requested imaging is not supported without the results of a chest x-ray relevant to the requested study.
The Plan must follow Medicare rules. Medicare rules say that CT 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 the LDCT. Our reviewer says that the requested LDCT is not considered medically reasonable and necessary. Our physician reviewer found the enrollee is 82 years old and does not meet the criteria for coverage of a LDCT scan. 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 LDCT have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan of the chest
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve skin graft surgery/Artacent Wound for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no current clinical need identified.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is a full thickness ulceration, so the requested surgery is medically reasonable and 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 surgery have been met. Therefore, we decided that the Plan has to pre-approve skin graft surgery/Artacent Wound 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on August 12, 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 the submitted medical records do not contain sufficient detail to support the billed charges.
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 the denied codes is: CPT 81240: F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant CPT 81241: F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant CPT 81291: MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) CPT 81400: Molecular pathology procedure, Level 1(eg, identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis). CPT 81401: Molecular Pathology Procedure Level 2
CPT 82955: Glucose-6-phosphate dehydrogenase (G6PD) We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the enrollee is treated for chronic pain. There is no indication that the enrollee is known to have, or thought to have, disorders of metabolism. The provided testing appears to have been part of a broad-sweeping screening process conducted of new patients by this provider. The documentation does not support that the provided testing was medically necessary and reasonable to diagnose, treat or otherwise manage this enrollee's condition(s). 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 services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on August 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on October 17, 2019.
You asked the Plan to pay for the assistant surgeon services. The Plan denied your request. The Plan says this type of provider is not eligible to bill assistant surgeon services.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 1, 2019 through September 8, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per Medicare, CPT code S9328 is a valid code. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
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 S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on September 1, 2019 through September 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on December 2, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider that has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the services you received on December 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered to you on November 20, 2019.
You asked the Plan to waive the copayment for these services. You say that the services were performed at an ambulatory surgical center. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for in-network Medicare-covered outpatient hospital surgery services.
Review of the file shows that you received outpatient surgery services in an outpatient hospital facility. You have been asked to pay a $400 copayment for these services. These services fall within the in-network Medicare-covered outpatient hospital surgery services 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 the outpatient surgical services rendered to you on November 20, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve ferric carboxymaltose injection (J1439).
You asked the Plan to pre-approve ferric carboxymaltose. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this drug should not be billed separately, but by the physician in a single bill along with their services.
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 ferric carboxymaltose. Our reviewer says that the requested ferric carboxymaltose is medically reasonable and necessary. Our physician reviewer found the ferric carboxymaltose is safe and effective for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ferric carboxymaltose have been met. Therefore, we decided that the Plan has to pre-approve ferric carboxymaltose injection (J1439).
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 pay for CPT code 26055 provided on November 1, 2019.
You asked the Plan to pay for CPT code 26055. You say that the medical records support the billing of CPT code 26055. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 26055.
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 26055 is Tendon sheath incision (eg, for trigger finger). 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 CPT code 26055. Our reviewer says that the medical records do not support the billing of CPT code 26055. Our physician reviewer found based on the documentation provided, the enrollee had a trigger finger, for which he received an injection, not an incision. Therefore, the billing of CPT 26055 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 26055 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 26055 provided on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided from July 24, 2019 to November 24, 2019.
You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you should not have to pay $58.54 and feels that it is too much. 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 20% of the cost for each Medicare-covered item. You have been asked to pay $35.80 which is 20% of the allowed amount for the oxygen concentrator on each date of service. The allowed amount is $179.03. ($179.03 x 20% = $35.80). The oxygen concentrator falls within the "Durable medical equipment (DME) and related supplies" 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 the oxygen concentrator provided from July 24, 2019 to November 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 16, 2019 through October 28, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that this admission was not due to a new problem. You say that this shouldn't be considered a new admission. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day, for days 1-5 and a $0 copayment per day, for days 6-90. For each Medicare-covered hospital stay, you are required to pay the applicable cost-sharing, starting with day 1 each time you are admitted. Cost-sharing does not apply on day of discharge. The enrollee has been asked to pay a $1,500 copayment for the inpatient stay. ($300/day x first 5 days = $1,500). The inpatient stay falls within the "Inpatient mental health care" benefit category. The records show that this was a separate inpatient admission. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from October 16, 2019 through October 28, 2019.
Your complaint about proper procedure not being followed is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 20, 2019.
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 above, are not covered. The test at issue in this appeal 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 September 20, 2019.