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

 
We decided that the Plan does not have to waive the cost for the echocardiography, stress test, myocardial 
perfusion imaging, medical supplies and regadenoson injection provided on May 28, 2020. 
 
You asked the Plan to waive the cost for the echocardiography, stress test, myocardial perfusion imaging, 
medical supplies and regadenoson injection. You say that the tests were administered on the same day at the 
doctor's office not in a hospital facility. You say that the second statement is a coding error. The Plan denied 
your request. The Plan says the cost share 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 20% 
coinsurance for each Medicare-covered medical supply, a $25 copayment for Medicare-covered non-
radiological diagnostic services, a $100 copayment for each Medicare-covered radiological diagnostic service 
and 20% coinsurance for each Medicare-covered Part B drug. 
  
 
 
You have been asked to pay a total of $401.94 for the echocardiography, stress test, myocardial perfusion 
imaging, medical supplies and regadenoson injection.  
 
Service Allowed Amount Standard Cost Member Liability 
Echocardiography $213.28 $100 $100 
Stress Test $64.17 $25 $25 
Myocardial Perfusion Imaging $488.66 $100 $100 
Medical Supplies $824.88 20% $164.97 
Regadenoson Injection $59.87 20% $11.97 
TOTAL:   $401.94 
 
The echocardiography, stress test, myocardial perfusion imaging and medical supplies fall within the 
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The regadenoson 
injection falls within the "Medicare Part B Prescription Drugs" benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost for the echocardiography, stress test, myocardial perfusion imaging, 
medical supplies and regadenoson injection provided on May 28, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Aranesp injection (J0881).You asked the Plan to pre-approveAranesp. You say that the service is medically necessary to treat the enrollee's condition.The Plan denied your request. The Plan says the rules for step therapy have not been met.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 Medicarerules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that this service is not reasonable or medically necessary. Our physician reviewer found there is no indication why Aranesp would be needed over Retacrit for this patient which the Plan has already approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Aranesp injection (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on January 29, 
2020, through April 29, 2020. 
 
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because 
these are per diem charges which substantiate the service. The Plan denied your request. The Plan says S codes 
are not payable by Original Medicare. 
 
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 indicator 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 January 29, 2020, through April 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forultrasounds (76641, 76982) provided July 28, 2020.You asked the Plan to waive the coinsurance forthe ultrasounds. You say that the ultrasounds were partof a screening mammogram and there should be no copayment.The Plan denied your request. The Plan says the screening service only includes mammography. The correct coinsurance was applied.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 20% coinsurance for Outpatient Diagnostic Tests. You have been asked to pay a 20% coinsurance for the ultrasounds. The ultrasounds fallwithin the Outpatient Diagnostic Tests 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 forultrasounds (76641, 76982) provided July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hot daily meals. 
 
You asked the Plan to pre-approve hot daily meals. You say that the member lives alone with a broken arm and 
cannot cook. The Plan denied your request. The Plan says their rules have not been met. The Plan must follow 
Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We 
looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage 
of hot daily meals have not been met. The records do not show that the member was discharged from a 
hospitalization recently. The member's EOC states, "The health plan contract says after a discharge from an 
acute inpatient hospital stay or skilled nursing facility, you may be eligible to receive 14 nutritious frozen 
meals delivered to your home. You are eligible to receive this benefit up to three (3) times per year. This 
benefit does not apply to discharges form an observation or inpatient mental health stay. Our meals provider 
will contact you to setup delivery." Therefore, we decided that the Plan does not have to pre-approve hot daily 
meals.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that 
were issued on July 7, 2020. 
 
You asked the Plan to pay for the compression stockings. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the item received is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 that were issued on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress. 
 
You asked the Plan to pre-approve a powered pressure-reducing air mattress. You say that you are having 
surgery and want to make things easier for your caregiver and self. The Plan denied your request. The Plan says 
the notes show you do not have any pressure ulcers so this request is denied. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The medical records do not show you have pressure ulcers. Based on 
this information, we decided that Medicare rules for coverage of a powered pressure-reducing air mattress have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a powered pressure-reducing 
air mattress.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from
May 13, 2020, through May 18, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 $325
copayment per day, for days 1-5 and a $0 copayment per day, for days 6-90 for inpatient hospital care.
You have been asked to pay $1,625 ($325 copayment x 5 days) for the inpatient hospital care provided. 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 inpatient hospital care provided from May 13, 2020,
through May 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), and the 
unspecified preventive dental service (D1999) provided on August 19, 2020. 
 
You asked the Plan to pay for the dental services. You say that you received a bill saying that the dental 
services you received were not covered. You say that something should have been sent to him in bold saying 
that his plan was changing. You say that you did not expect this drastic change in your coverage. The Plan 
denied your request. The Plan says routine dental services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The record shows that the Annual Notice of Changes (ANOC) for 2020 says routine dental 
care is not covered. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), 
prophylaxis (D1110), and the unspecified preventive dental service (D1999) provided on August 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on September 2, 
2020 and September 3, 2020. 
 
You asked the Plan to waive the copayment for the chest x-rays. You say that there was a problem with the first 
x-ray, so you had to redo it. You say that you are now being charged two copayments. The Plan denied your 
request. The Plan says the copayments 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 $10 
copayment after the deductible is met for each basic imaging service.  
 
You have been asked to pay a $10 copayment for each chest x-ray. The total amount you owe is $20 ($10/x-ray 
x 2 x-rays = $20). The chest x-rays fall within the "Outpatient diagnostic tests and therapeutic services and 
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 copayment for the chest x-ray provided on 
September 2, 2020 and September 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally 
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and 
placement of transfixing device (CPT Code 27279). 
 
 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 services. Our physician reviewer 
found the patient has NOT had two diagnostic SI joint injections which provided greater than 75% pain relief. 
The RFA of the SI joint did NOT provide relief. Therefore, the requested SI joint fusion 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), 
with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT 
Code 27279).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveTruxima (Q5115).

You asked the Plan to pre-approveTruxima. You say that Truxima is medically necessary.The Plan denied your request. The Plan says a trial of Rituxan (rituximab) or Ruxience (rituximab-pvvr) is required before alternatives can be considered.

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 Truxima. Our reviewer says that Truxima is not medically necessary. Our physician reviewer found the health plan requires preferred drugs Rituxan (rituximab) or Ruxience (rituximab-pvvr). There is no indication why these could not be used for the patient.


We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Truxima have not been met.Therefore, we decided that the Plan does not have to pre-approveTruxima (Q5115
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe targeted genomic sequence analysis panel coded 81455 provided on February 10, 2020.You asked the Plan to pay forthe targeted genomic sequence analysis panel. 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 supported by the documentation.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 81455 is targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed.We find that CPT code 81455 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition form or medical records stating exactly what tests were to be performed. The submitted Laboratory Requisition indicates that as portfolio level of service was requested. The submitted documentation does not itemize what tests are included in this level of service. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met.Therefore, we decided that the Plan does not have to pay forthe targeted genomic sequence analysis panel coded 81455 provided on February 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown (D2740 for tooth # 21 provided on June 11, 2020.You asked the Plan to pay forthe dental service. You say that you were advised that the crown was not covered because of a root canal. You say that you did not receive a root canal. You also say that you should not have to pay more than you already have for the crown.The Plan denied your request. The Plan says the crown is not medically necessary. The Plan also says that the documentation provided shows that thecompleted root canal treatment on tooth # 21 does not meet clinically acceptable standards for root canal therapy.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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the crown is not medically necessary. Our physician reviewer found the provided documentation shows that tooth # 21 has previously been treated withendodontics and sealed with an amalgam restoration. The reviewer found that the root canal filling on the tooth only appears to fill about half of the canal space. The reviewer found that this tooth does not meet the standard of care for endodontic treatment and should not be further restored until the deficient root canal is retreated. Therefore, the reviewer found that the crown is not medically necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met.Therefore, we decided that the Plan does not have to pay forthe crown (D2740 for tooth # 21 provided on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the optometry services (92015, 92134, & 99204) provided on January 28, 2020.
You asked the Plan to pay for the optometry services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent. There were network providers available.
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 service 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 optometry services (92015, 92134, & 99204) provided on January 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 31, 2020, to June 29, 2020.
You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the rules for SNF care have 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 above 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary.
Our physician reviewer found there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Furthermore, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from May 31, 2020, to June 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided on September 2, 2020.
You asked the Plan to pay for the acupuncture services. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the rules for acupuncture coverage have not been met.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the services provided were not performed by a licensed physician as specified by the enrollee's contract. Therefore, we decided that the Plan does not have to pay for the acupuncture services (97810, 97811) provided on September 2, 2020.