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

We decided that the Plan does not have to pay for ambulance services provided on August 16, 2018.
You asked the Plan to pay for the remaining claims for ambulance services. You say that there were two round trip transports. The Plan denied your request. The Plan says they paid for two claims of a round trip transport and the remaining two claims are duplicates.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file and Medicare rules. There is no evidence provided that there was another round trip transport on that day. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the two remaining claims for ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and the pontics (D6245 x 2) provided on April 5, 2019.
You asked the Plan to pay for the dental services. You say that you were advised to wait until the treatment was finished to submit a claim for reimbursement. You say that you were never advised that claims needed to be submitted within 60 days. You also say that you decided to go with a bridge instead of implants due to the expense. The Plan denied your request. The Plan says retainer crowns and pontics are not covered services.
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 retainer crowns and pontics are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the retainer crowns (D6740 x 2) and the pontics (D6245 x 2) provided on April 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 2, 2019 and billed under code 81479.
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 Current Procedural Terminology (CPT) code 81479 (1 Unit) remains not supported. The documentation submitted did not include documentation of an unlisted molecular pathology procedure for the billed date of service; therefore, the billed service cannot be verified. The laboratory results submitted indicate the specimen was collected on July 2, 2019 and received by the lab on July 5, 2019. It should also be noted the submitted GeneSight Order is dated after the billed date of service and is unsigned by the ordering physician. Furthermore, it should be noted the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. The Plan states that multiple attempts were made to contact the provider for additional information.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes. In this case, this claim cannot be paid as billed based on discrepancies with the POS codes billed. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 2, 2019 and billed under code 81479.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen 20,000 units/ml vial 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 there is already an approval for Retacrit.
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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not contain documentation that Retacrit (Epoetin alfa-epbx) has been tried and failed. The documentation does not support that Retacrit (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Epogen 20,000 units/ml vial for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307 and G0480) provided to the enrollee on March 4, 2019.
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 based on Medicare billing guidelines, codes 80307 and G0480 remain not supported. The Plan states that the place of service (POS) code on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory or POS code 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting or POS 11. Also, the laboratory results submitted indicate the specimen was collected on March 4, 2019 and received by the lab on March 5, 2019. It is noted multiple attempts were made to obtain additional information from the provider without success.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate POS code. In this case the claim submitted cannot be paid due to an error with the POS codes reported. The Plan states a corrected claim would be reviewed if submitted. Therefore, we decided that the Plan does not have to pay for lab services (80307 and G0480) provided to the enrollee on March 4, 2019.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 5 fractions of stereotactic body radiation therapy (SBRT) for the enrollee.
You asked the Plan to pre-approve SBRT services. The Plan denied your request. The Plan says that palliative regimens do not include SBRT.
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 SBRT services. Our physician reviewer found that SBRT has been demonstrated to achieve durable tumor control when treating lesions in vertebral bodies or the paraspinous region, where extra care must be taken to avoid excess irradiation of the spinal cord when tumor-ablative doses are administered. There is an important clinical distinction between the status of patients described above and a patient with widely metastatic disease for whom palliation is the major objective. In one setting, a patient with limited metastatic disease and good performance status is treated with the intention of eradicating all known active disease or greatly reducing the total disease burden in a manner that can extend progression free survival. For such a patient, SBRT can be a reasonable therapeutic intervention. This enrollee has only one lesion known to be active. SBRT is within the accepted standards of care. It would meet the general medical necessity criteria by virtue of treatment furnished according to accepted standards of medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SBRT services have been met. Therefore, we decided that the Plan has to pre-approve 5 fractions of stereotactic body radiation therapy (SBRT) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that the member's medical and therapy needs are stable and do not require a SNF level of care.
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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Megestol AC for the enrollee.
You asked the Plan to pre-approve Megestol AC. You say that the enrollee is having a hard time sleeping due to hot flashes. The Plan denied your request. The Plan says that this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Megestol AC for the enrollee.
Benefits for Megestol AC 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zoledronic acid.
You asked the Plan to pre-approve Zoledronic acid. You say that the enrollee's GERD is a contraindication for oral bisphosphonates. The Plan denied your request. The Plan says the enrollee does not have an intolerance or contraindication for oral bisphosphonates.
The Plan follows Medicare rules. Medicare rules say that Zoledronic acid is covered when there is demonstrated intolerance or contraindication for oral bisphosphonates and the medical record clearly supports the need for the intravenous administration of bisphosphonates for the treatment of osteoporosis. 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 Zoledronic acid. Our reviewer says that the requested medication is not medically necessary. Our physician reviewer found the enrollee is reported to have osteoporosis, but no test results confirming this diagnosis have been submitted for review. The appeal documentation reports a history of GERD, but the office notes note no history of GERD and no GERD medications. There is no evidence that the enrollee has taken oral bisphosphonates and been found to be intolerant or non-responsive to these medications. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zoledronic acid have not been met. Therefore, we decided that the Plan does not have to pre-approve Zoledronic acid.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on October 16, 2019 by an out of network (OON) provider.
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 the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan 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 physician services provided on October 16, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you'll benefit from rehab. The Plan denied your request. The Plan says the admission is not medically necessary.
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 pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you were admitted to the hospital on March 30, 2020 with acute kidney injury. You need assistance with walking 280 feet with a rolling walker. You need minimal supervision with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on June 4, 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 procedure codes 99308 and 17004 are not supported.
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 99308 is Level 2 subsequent nursing facility visit, typically 15 minutes per day. The definition of code 17004 is destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions. We find that CPT codes 99308 and 17004 are not supported in the medical record. Specifically, there is no documentation of subsequent nursing care time spent on the enrollee to support code 99308. There is no documentation of destruction of 15 or more lesions to support code 17004. 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 pay for the services rendered on June 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital stay provided from September 11, 2019 to September 16, 2019.
You asked the Plan to reduce the copayment for the inpatient hospital stay. You say that you should not be charged for the additional days because you were waiting for approval to the skilled nursing facility. 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 a $295 copayment per day (per Medicare-covered stay), days 1-5, which includes day of admission and days of discharge. You have been asked to pay a $295 copayment for each day the inpatient hospital stay. ($295 x 5 days = $1,475). The inpatient hospital stay falls within the "Inpatient hospital care" 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 reduce the copayment for the inpatient hospital stay provided from September 11, 2019 to September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 4, 2019 and billed under codes 82306 and 84443.
You asked the Plan to pay for this service. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says while codes 80053, 80061, and 85025 will be paid, codes 82306 and 84443 were performed for screening purposes and are not covered under Medicare. The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed above, are not covered. The codes 82306 and 84443 were performed 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 lab services provided to the enrollee on September 4, 2019 and billed under codes 82306 and 84443.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on June 4, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that you were informed your copayment would be $10. 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). Your contract with the Plan clearly says that you must pay a $40 copayment for physical and speech therapy. You have been asked to pay a $40 copayment for the physical therapy visit. Physical therapy falls within the "Outpatient rehabilitation 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 physical therapy provided on June 4, 2019.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiography. We decided that the Plan does
not have to pre-approve OON services
You asked the Plan to pre-approve a transthoracic echocardiography by an OON provider. The Plan says that
the enrollee's only complaint was that of increasing fatigue.
We decided that the Plan has to pre-approve a transthoracic echocardiography.
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 for a transthoracic echocardiography Our physician
reviewer found that the enrollee has uncontrolled hypertension and borderline left ventricular hypertrophy by
electrocardiography. In this circumstance an echocardiogram is reasonable and appropriate to assess both LV
mass and LV function, which in turn may help guide choice of antihypertensive medication and also guide
intensity of management in this elderly enrollee.
Cardiac effects of hypertension, particularly uncontrolled hypertension, is an accepted and appropriate
indication for echocardiography in the medical community. Therefore, the requested service is considered
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 testing have been met. Therefore, we decided that the Plan has to preapprove
a transthoracic echocardiography for the enrollee.
We also decided that the Plan does not have to pre-approve OON services.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
OON 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for screening testing provided on September 27, 2019.
You asked the Plan to pay for screening tests. You say that you are requesting reconsideration. The Plan denied your request. The Plan says the denial of payment for these services is correct, because predictive screening testing is not a Medicare benefit.
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 tests at issue in this appeal, screening tests, were requested for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for screening testing provided on September 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra eye drops for the enrollee.
You asked the Plan to pre-approve this drug. You say that the member has severe dry eye and has failed other medications. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra eye drops for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.