Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve additional physical therapy (PT) visits (97164).

You asked the Plan to pre-approve the additional PT visits. You say that the plan should continue to allow rehab as the enrollee will make progress and also needs to be at a certain level of independence until it is safe to return home. Since the physical therapy stopped he has declined. The Plan denied your request. The Plan says that additional PT visits is not medically necessary and the enrollee does not meet the Medicare criteria for coverage.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional PT visits. Our reviewer says that the requested items/service is considered medically necessary in this case. Our physician reviewer found the enrollee was referred to PT due to a decline in function related to COVID-19. The plan approved 10 PT visits. The case file contains limited documentation, with a PT Evaluation & Plan of Care. The enrollee was noted to have impaired strength in his right and left lower extremities. The enrollee ambulated 20 feet with a wheeled walker with minimal assist. The potential for achieving PT goals was noted to be good. The limited clinical documentation does not support the plan's denial of additional PT visits.

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 additional PT visits have been met. Therefore, we decided that the Plan has to pre-approve additional physical therapy (PT) visits (97164).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network provider.

You asked the Plan to pre-approve wound care. You say that you have seen this doctor once a week for three years. You say that the in-network provider is harder to access, and you would have to start all over with a new doctor. The Plan denied your request. The Plan says services are available in-network.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve wound care to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.
You asked the Plan to pre-approve Synvisc. You say that you are requesting Synvisc. The Plan denied your request. The Plan says Synvisc is not a preferred drug under your plan.
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 Synvisc. Our reviewer says that Synvisc is not medically reasonable and necessary for you. Our physician reviewer found based on the medical records provided, you have not tried and failed the required drugs, Euflexxa and Gel-One. Our reviewer also found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for fracture treatment (25600) provided on September 25, 2020.
You asked the Plan to pay for fracture treatment. You say that this was medically necessary. The Plan denied your request. The Plan says the units billed exceed the MUE for this code.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 25600 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of fracture treatment have not been met. Therefore, we decided that the Plan does not have to pay for fracture treatment (25600) provided on September 25, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve oncology mRNA gene expression profile testing.

You asked the Plan to pre-approve genetic testing. You say that the enrollee had a complicated result on prior testing. The Plan denied your request. The Plan says that the denial of authorization for this testing is correct, because this test is not medically necessary.

The Plan follows Medicare rules. Medicare rules state that oncology mRNA gene expression profile testing may be considered medically necessary to guide therapeutic decision-making in patients with certain clinical findings.

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 genetic testing. Our reviewer says that the enrollee meets the Medicare criteria for the requested testing. Our physician reviewer found HER2 heterogeneity is an ongoing topic of study. Patients with low percentages of HER2 positivity may represent a unique group from those that have higher rates of HER2 positivity and may have resistance to HER2 base therapy. Given only HER2 positivity was seen in the biopsy specimen and not on final surgical pathology an Oncotype Dx was sent to further characterize the tumor. Some may have considered the tumor to be HER2 negative based on final pathology and in an effort to avoid chemotherapy genomic profiling of the tumor was performed. The service is reasonable and medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pre-approve oncology mRNA gene expression profile testing.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for code 72710 provided to the enrollee.

You asked the Plan to pay for this service as billed. You say that this claim should be paid, and a modifier is not needed. The Plan says that they have overturned payment for codes Q0092 and R0070. The Plan states they continue to deny code 72710 (Radiologic examination, pelvis; 1 or 2 views) because the modifier was not billed on the claim to represent the service as separate/distinct based on CMS NCCI Procedure-to-Procedure code pair edits and Per CMS NCCI Policy Manual, Chapter 1.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary the appropriate modifier. In this case, code 72710 cannot be paid due to the omission of the required modifier on the claim. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee and billed under code 72710.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services.

You asked the Plan to waive the coinsurance for laboratory services. You say that this was a normal blood test that the doctor requested. You say that you should not be paying for this. The Plan denied your request. The Plan says the coinsurance 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 50% coinsurance for lab services at an out-of-network freestanding laboratory.

You have been asked to pay $102.99, which is 50% of the allowed amount for the laboratory services. The allowed amount is $206.04 (50% x $206.04 =$102.99). Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show the provider is an out-of-network independent laboratory. 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 laboratory services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services 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 the enrollee did not have prior authorization for out of network vision 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for vision services provided to the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) physical therapy visits (CPT code 97110), for the enrollee to be performed by an out-of-network provider.

You asked the Plan to pre-approve the physical therapy visits. You say that the provider is out-of-network, but the enrollee has out-of-network benefits and a preference of going to their office. The Plan denied your request. The Plan says there is no medical need shown as to why the enrollee cannot get this physical therapy from a network provider.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve twelve (12) physical therapy visits (CPT code 97110), for the enrollee to be performed by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services.

You asked the Plan to waive the copayments for the PT services. You say that you should not have to pay all of these copayments. You say that on some of the dates of service, you did not receive therapeutic exercises. The Plan denied your request. The Plan says you were charged these copayments 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 $20 copayment for each outpatient rehabilitation service, treatment, or evaluation.

Records show that you received PT services on three days. You have been asked to pay a $20 copayment for each of these three PT dates of service. The PT services fall within the outpatient rehabilitation service, treatment, or evaluation benefit category. This copayment applies regardless of the extent of the PT services you receive on each day. 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 copayments for physical therapy (PT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (J1030) provided to the enrollee on August 24, 2020.
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 HCPCS J1030 remains 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 J1030 is "Injection, methylprednisolone acetate, 40mg." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure reports documents an injectate was given; however, the operative report does not include documentation that methylprednisolone acetate was given. Therefore, this medication cannot be confirmed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (J1030) provided to the enrollee on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable patient lift (E0630).

You asked the Plan to pre-approve a portable patient lift. You say that this is necessary for you to get into vehicles and to medical appointments. The Plan denied your request. The Plan says this is not covered for the requested use.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable patient lift (E0630).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for breast tomosynthesis (G0279) provided from May 5, 2020, to June 12, 2020.
You asked the Plan to pay for breast tomosynthesis. You say that this is supported in the records. The Plan denied your request. The Plan says the documentation does not support the billed dates of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We find that CPT code G0279 is not supported in the medical record as billed. Specifically, this code was billed for a date range of May 5, 2020, to June 12, 2020, but medical records have only been submitted for May 5, 2020. Without records for the billed dates of service, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for breast tomosynthesis (G0279) provided from May 5, 2020, to June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on September 14, 2020.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this is the only service provider for this medically necessary testing. The Plan denied your request. The Plan says there is a more appropriate CPT code to report the service billed.

The Plan must follow Medicare rules. Medicare rules say that the Guardant360 testing is covered when certain criteria are met. One unit of CPT code 81479 is used to report this testing.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Specifically, CPT code 81479 is used to report Guardant360 testing. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brilinta tablets.
You asked the Plan to pre-approve Brilinta tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Brilinta tablets are not covered under the enrollee's Medicare Part B benefit.
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 Brilinta tablets.
Benefits for Brilinta tablets 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance services provided on October 22, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to obtain authorization before receiving services. 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 non-emergent ambulance services in this case were provided by an out-of-network provider. The Plan required prior authorization for non-emergent out-of-network services. 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 non-emergency ambulance services provided on October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Victoza 18MG/3ML Injection, for the enrollee.
You asked the Plan to pre-approve the medication. You say that the enrollee would significantly benefit from Victoza to better control their diabetes in a safe way, while also helping decrease his risk of any cardiovascular complications in their life. The Plan denied your request. The Plan says this medication does not fall under the enrollee's Part B benefits. This medication is covered under Part D benefits, but the enrollee does not have a commercial pharmacy benefit with the Plan.
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 Victoza 18MG/3ML Injection, for the enrollee.
Benefits for the medication 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 the lab services provided on September 23, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is no documentation that shows the intent for the genetic testing.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the lab services provided on September 23, 2020.