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

We decided that the Plan does not have to waive the copayment for the x-ray of the spine (72100) provided on October 27, 2020.

You asked the Plan to waive the copayment for the x-ray. You say that this was not an x-ray provided at an outpatient hospital facility, it was provided on the same floor of the building where you see your primary care provider. The Plan denied your request. The Plan says the facility that provided and billed for this service is a hospital facility. Therefore, 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). Your contract with the Plan clearly says that you must pay a $110 copayment for basic radiological services provided at an outpatient hospital facility. 

You have been asked to pay a $93.09 copayment for the x-ray. The x-ray falls within the basic radiological services benefit category and was provided at an outpatient hospital facility. 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 x-ray of the spine (72100) provided on October 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xolair.

You asked the Plan to pre-approve Xolair. You say that the records provided support the enrollee's need for the requested drug. You say that if the insurance company requires you to buy and bill the medication, you are unable to do that. The Plan denied your request. The Plan says the enrollee does not have a pharmacy benefit with this Plan. The Plan says that Xolair is covered by the pharmacy benefit.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication is dispensed by a pharmacy and would then be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Xolair.

Benefits for Xolair 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0012M).

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary. The Plan denied your request. The Plan says this type of testing is not covered.

The Plan must follow Medicare rules. Medicare rules say that CxBladder testing (0012M) is not a covered service.

We looked at the file and Medicare rules. This type of testing is not covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image.

You asked the Plan to pay for the panoramic radiographic image. You say that you went for a routine dental check up and assumed that you would not be responsible for anything except the copayment. The Plan denied your request. The Plan says the services received are not a covered benefit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services.

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 that the claim was not billed with the required taxonomy code.

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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the claim was not submitted with a required taxonomy code; however, the original claim form was not provided by the Plan. Without this claim form, a determination based on billing of the claim cannot be supported. Therefore, we decided that the Plan has to pay for the laboratory services.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve the additional routine transportation trips. You say that you have additional medical appointments that you require transportation to. The Plan denied your request. The Plan says your request for additional routine transportation trips exceeds the benefit allowance for the calendar 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 one-way routine transportation trips per year.

We looked at your request, the records in the case file, and the rules. The records show that you have received coverage for 24 one-way routine transportation trips in the 2021 calendar 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 pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care that you provided.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says this service required 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the subsequent nursing facility care. 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 that you provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.

You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says this service required 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the subsequent nursing facility care. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab testing services (82533, 82088, 36415, 80048).

You asked the Plan to waive the copayment for the lab services. You say that you did not realize you would have a copayment for this service. The Plan denied your request. The Plan says you are responsible for a $15 copayment for lab services completed in an outpatient hospital facility. This information is available to you in the Plan's contract.

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 $15 copayment for outpatient lab services.

You have been asked to pay a $15 copayment for lab services. 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 lab testing services (82533, 82088, 36415, 80048).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyzulta.

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 self-administered drugs are not covered.

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 Vyzulta.

Benefits for these services 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 pre-approve bilateral knee genicular nerve block procedures.

You asked the Plan to pre-approve Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (64454). You say that the enrollee needs this procedure for pain relief. The Plan denied your request. The Plan says genicular nerve block for treatment of chronic pain is considered to be experimental and investigational.

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 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (64454). 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 that is the subject of on-going clinical trials. Therefore, the request is considered 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 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (64454) have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral knee genicular nerve block procedures.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483).

You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code G0483 is not supported in the medical record. Specifically, the Place of service billed (POS 81, laboratory) does not match the place of service where the records show the specimen was obtained (POS 11, office setting). 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 (G0483).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services.

You asked the Plan to pay for the physician's services. You say that The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. 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 physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography angiogram (CTA) of the pelvis described by code 72191.
You asked the Plan to pre-approve the CTA of the pelvis. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a condition for which this imaging is needed.
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 CTA of the pelvis. Our reviewer says that the imaging code selected in this case is not shown to be medically reasonable and necessary. Our physician reviewer found the patient clearly has hypertension and the duplex scan referenced in the notes (no formal report) indicates at least bilateral 50% stenosis. As such, the next step would be CTA of the renal arteries which is coded 74175. The type of imaging requested via code 72191 would not include images of the arteries of interest. If the correct code were requested, approval could be considered. 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 CTA of the pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography angiogram (CTA) of the pelvis described by code 72191.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection, methylprednisolone acetate, 80 mg provided to the enrollee on April 27, 2020.
You asked the Plan to pay for an injection, methylprednisolone acetate, 80 mg. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our 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 an injection, methylprednisolone acetate, 80 mg. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the documentation submitted do not show this billed service was provided. The procedure report documents "1 ml Methylprednisolone and 3 ml 0.25% Marcaine" was given. Documentation does not support 80 mg given, therefore J1040 cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an injection, methylprednisolone acetate, 80 mg have not been met. Therefore, we decided that the Plan does not have to pay for an injection, methylprednisolone acetate, 80 mg provided to the enrollee on April 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing.

You asked the Plan to pay for the testing services. You say that the testing provides the most advanced and informative medical analytics. The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed on the claim.

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 testing at issue in this appeal was requested for screening purposes. The medical records provided do not indicate the testing was ordered as part of a specific treatment strategy for the enrollee. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for the genetic testing.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient surgery services.

You asked the Plan to waive the copay for the services provided. You say that you were never informed that you would be responsible for any payments. The Plan denied your request. The Plan says the claim processed correctly per your benefit package.

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 $350 copay for outpatient surgery.

You have been asked to pay a $350 copay for the services provided. The services fall within the outpatient surgery 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 copay for the outpatient surgery services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the negative pressure wound therapy (NPWT)(E2402) provided to the enrolle.

You asked the Plan to pay for the NPWT. You say that the claim should be paid. The Plan denied your request. The Plan says there was no physician order for the DME at issue.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid physician order which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the negative pressure wound therapy (NPWT)(E2402) provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided to the enrollee.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria were not met.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the review indicates that all inpatient care provided through transfer was not medically necessary or reasonable at the non-plan facility.

The enrollee was medically stable, and the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization care provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound dressing.

You asked the Plan to pay for the services provided. You say that prosthetic devices are paid under Part B to the provider. The Plan denied your request. The Plan says the services are included in the facility payment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.

Records show that the services provided was used in a SNF. Therefore, we decided that the Plan does not have to pay for the wound dressing.