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

We decided that the Plan does not have to pay for the drug services rendered on August 28, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that all drugs, including Prodrugs, are reported to DME MACs by National Drug Code (NDC). We looked at the file and Medicare rules. The claim was not billed with the required NDC number. 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 drug services rendered on August 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 24,2020.
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 this claim denied because it is bundled to another service billed on the same day by the
same physician, or a physician of the same specialty in the same group, which is considered the same provider.
Per CMS NCCI Procedure-to-Procedure code pair edits, code 74176 is a column II to column I code 74174
(Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including non-contrast
images, if performed, and image postprocessing), billed by another provider. This code pair has a modifier
indicator of "1", which is defined: "The modifiers associated with NCCI are allowed with this PTP code pair
when appropriate." Per CMS NCCI Policy Manual, Chapter 1, "Occasionally, a provider may perform two
procedures that should not be reported together based on an NCCI PTP edit. If the edit allows use of NCCI
PTP-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both
services may be reported with the NCCI PTP-associated modifier." A modifier was not billed on the claim to
represent the services as separate/distinct.
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 required the appropriate modifiers.
In this case, the claim submitted cannot be paid as billed due to an issue with the physician relationship with a
claim previously billed and the lack of a modifier to demonstrate a separate service. Medicare rules for
coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for
imaging services provided to the enrollee on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe knee scooter (E0118).You asked the Plan to pre-approvethe knee scooter. You say that you would like reconsideration because you are being treated for a stress fracture and crutches hurt your back.The Plan denied your request. The Plan says there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicare population to establish the medical necessity for these products.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met. Specifically, there is insufficient published clinical literature demonstrating safety and effectiveness in the Medicarepopulation to establish the medical necessity for these products.Therefore, we decided that the Plan does not have to pre-approvethe knee scooter (E0118).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the enrollee has not tried and failed Inflectra or Remicade; and Stelara.
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 Entyvio. Our physician reviewer found that you have a history of Crohn's disease. The Plan requires a trial of Inflectra or Remicade; and Stelara before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective, or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on September 16, 2020.You asked the Plan to waive the copayment for lab work. You say that if this was done in the office you wouldn't have a copayment for this. The Plan denied your request. The Plan says the correct copayment has been 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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a $10 copayment for lab work. When additional services are performed that go beyond an office visit/telehealth visit, additional copayments are applied; therefore, the correct copayment has been applied. Lab work falls within the outpatient diagnostic tests/laboratory 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 copayment for lab work provided by a participating provider on September 16, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituximab injection, 10 mg.
You asked the Plan to pre-approve Rituximab injection. You say that the requested drug is medically
necessary. The Plan denied your request. The Plan says that your condition is not an approved condition for
this medication. The Plan also says that this medication is not medically reasonable or necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Rituximab injection. Our reviewer says
that the requested use of Rituximab injection meets the criteria for coverage. Our physician reviewer found the
requested use of Rituximab is not FDA-approved for the enrollee's diagnosis. The reviewer found that the use
is supported by clinical research that appears in a CMS-approved medical journal, Rituximab versus
cyclophosphamide for ANCA-associated vasculitis with renal involvement, from the Journal of the American
Society of Nephrology. The reviewer also found that the use is not listed as not indicated, not supported or not
recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Rituximab injection have been met. Therefore, we decided that the Plan has to
pre-approve Rituximab injection, 10 mg.
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 pay forthe wheelchair van services provided on August 27, 2020.You asked the Plan to pay forthe wheelchair van services. You say that you were unable to meet the 3-day requirement for scheduling non-emergency transportation.The Plan denied your request. The Plan says wheelchair van transportation is not a Medicare-covered benefit and you did not request non-emergency transportation services at least 3 days in advance.The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. Medicare also 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 routine transportationserviceswhen they are scheduled at least 3 days in advance. We looked at your request, the records in the case file, and the rules. The file indicates that you did not schedule the transportation within at least 3 days of the date of service. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met.Therefore, we decidedthat the Plan does not have to pay forthe wheelchair van services provided on August 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ophthalmic imaging provided on
September 14, 2020.
You asked the Plan to waive the deductible for the ophthalmic imaging. You say that you have never paid a
deductible before with this Plan. 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. Your
contract with the Plan says that there is a $250 deductible that applies towards the ophthalmic imaging.
The ophthalmic imaging you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The record shows the ophthalmic imaging is
considered an outpatient diagnostic service.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that
applies towards the ophthalmic imaging. This cost sharing is a contractual obligation that had not been met at
the time the ophthalmic imaging was received on September 14, 2020. Therefore, we decided that the Plan
does not have to waive the deductible for the ophthalmic imaging provided on September 14, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from March 15, 2020, to
March 18, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the records provided support the
services billed. The Plan denied your request. The Plan says that the level of care provided was not medically
necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the enrollee was admitted to the emergency department on March 15, 2020, complaining of
lower back pain after a fall. The evaluation revealed an abnormal urine analysis. The EKG was without an
acute ischemic changes and the CT of the lumbar spine revealed extensive degenerative changes without any
acute facture. The enrollee was treated with an IV of Ceftriaxone and an IV of morphine for pain control. The
enrollee underwent an echocardiogram and was discharged to a skilled nursing facility when considered
medically stable on March 18, 2020. The records show that at the time of inpatient admission, the admitting
physician reasonably expected that the enrollee's necessary hospital care would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from March 15, 2020, to March 18, 2020.
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 waive the copayment for the laboratory services rendered on
September 22, 2020.
You asked the Plan to waive the copayment for these services. You say that the copayment should be waived.
The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for Medicare-covered laboratory tests.
Review of the file shows that you received laboratory services on September 22, 2020. These services fall
outside of the scope of an annual wellness visit. Per the contract with the Plan, there is a $10 copayment for
Medicare-covered laboratory tests. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. However, the Medicare allowed amount for these services is $8.46. Given that the allowed
amount was less than the $10 copayment, you have been asked to pay $8.46 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered
on September 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because
the member has been in the hospital for 6.5 weeks and has conditions which would best be monitored in an
LTACH setting. The Plan denied your request. The Plan says these services can safely be rendered in a lower
level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services at the LTACH that the member requires that are not already
available and covered at the current facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three core buildups, including any pins when required
(D2950 x3).
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service
is not covered.
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 pre-approve three
core buildups, including any pins when required (D2950 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechiropracticservices.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says the enrollee has failed to respond with symptom improvement to the initial chiropractic treatments.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. The file shows that therapeutic exercises, and massage therapy were requested. Theseservices arenot manual manipulation of the spine.Based on this information, we decided the Medicare rules for coverage of chiropractic services have not been met.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 requested services. Ourphysician reviewer found that the only treatment allowed by Medicare for chiropractors is to treat a subluxation of the spine. There are no submitted imaging studies to reveal evidence of a subluxation. The submitted chart notesreveal the same or similar findings of +1/4 tenderness to palpation in the areas of the cervical paraspinals, left trapezius, upper thoracic paraspinals and right trapezius, with spasms of the cervical paraspinals, left and right trapezius and thoracic paraspinals. Theydo not reveal evidence of subluxation. The documentation does not show evidence that further clinical improvement can reasonably be expected from continuous ongoing care. Therefore, the requested services are 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 have not been met.Therefore, we decided that the Plan does not have to pre-approvechiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) and cone
beam computed tomography (CT) capture (D0367) provided on September 1, 2020.
You asked the Plan to pay for the comprehensive periodontal evaluation and cone beam CT capture. You say
that you believe the services you received should be covered. The Plan denied your request. The Plan says
these services are not covered benefits.
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
comprehensive periodontal evaluation (D0180) and cone beam computed tomography (CT) capture (D0367)
provided on September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mouth guard for teeth grinding (D9945).
You asked the Plan to pre-approve the dental item. You say that the mouth guard is not for cosmetic purposes.
You say that it is chipping away your permanent teeth. You also say that you would like to save your teeth
instead of having to have dentures once your teeth are messed up. The Plan denied your request. The Plan says
mouth guard for teeth grinding is not listed as a covered dental item.
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. The Customer Handbook clearly states that if a dental item or service
is not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to preapprove a mouth guard for teeth grinding (D9945)
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Emergency Department visit provided on May 22, 2020.The provider submitted the claim tothe Plan to pay forthe Emergency Department visit. You say that this claim should be submitted to Workers Compensation Boardnot Medicare.The Plan denied this claim. The Plan says the provider submitted this claim as a work-related injury for which charges are not covered.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has sent this claim and your Workers Compensation information to its subrogation department to handle this issue. As the secondary insurer, the Plan cannot be held responsible for the Emergency Department visit until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe Emergency Department visit provided on May 22, 2020.