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

We decided that the Plan does not have to pay for the laboratory services rendered on May 8, 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 screening tests are not covered.
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 test at issue in this appeal was requested 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 the laboratory
services rendered on May 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PRALUENT 75 mg/ml pen.
You asked the Plan to pre-approve PRALUENT. You say that this drug is necessary to treat the enrollee's
medical condition. The Plan denied your request. The Plan says this drug is not covered for you condition by
your plan. Medicare says Part B programs can only provide limited benefits for
prescription drugs.
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 PRALUENT 75 mg/ml pen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional reimbursement for eyeglass frames providedon August 6, 2020.You asked the Plan to provide additional reimbursement for the eyeglass frames. The Plan denied your request. The Plan says the $100 eyewear allowance was applied to the total bill.Medicare generally does not cover routineeyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules applyin this case.We looked at the file and the Plan's rules. The file shows that the $100 eyewear allowance was applied to the total bill. Therefore, we decided that the Plan does not have to provide additional reimbursement for eyeglass frames providedon August 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that you have not had a change in function warranting daily skilled therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factorslisted 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 your condition does not meet Medicare criteria for 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-approveskilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye examination provided on July 13,
2020.
You asked the Plan to waive the copayment the eye examination. You say that it is your understanding that
your vision coverage allows for one exam per year at no cost to you. The Plan denied your request. The Plan
says there is a $45 copayment for each Medicare covered exam to diagnose and treat diseases or conditions of
the eye.
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 $45
copayment for Medicare-covered vision care.
You have been asked to pay a $45 copayment for the eye examination. The eye examination falls within the
Medicare-covered vision 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 waive the copayment for an eye
examination provided on July 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99601, CPT 99602) provided on March 14, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Codes 99601 and 99602 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (CPT 99601, CPT 99602) provided on March 14, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Pegfilgrastim (CPT Code J2505).You asked the Plan to pre-approve the medication. You say that the medication is necessary.The Plan denied your request. The Plan says that the requested drug is supported if the member is receiving drugs that have high or medium risk of developing a fever related to a low white blood cell count that is not normal. The Plan states the records do not show that this applies to the member.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 safeand 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 the medication. Our physician reviewer found the requested use of Pegfilgrastim (CPT Code J2505) is FDA-approved for the enrollee's diagnosis. FDA approved to decrease the incidence of infection (as manifested by febrile neutropenia), in patients with nonmyeloid malignancies receiving myelosuppressive cancer chemotherapy associated with a clinically significant incidence of febrile neutropenia. Based on the patient's age, regimen, prior chemotherapy and neutropenia the enrollee has a greater than 20% risk of neutropenia.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 medication have been met.Therefore, we decided that the Plan has to pre-approve Pegfilgrastim (CPT Code J2505).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services provided on May 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were provided by a provider who is not eligible to enroll in Medicare.
The Plan must follow Medicare rules. Medicare rules say that the services of a nurse practitioner (NP) may be covered under Part B if the above criteria are met. We looked at the file and Medicare rules. The code in question is a payable code for physician services. There is no evidence that the provider does not meet the definition of an NP and she has a valid NPI number. No evidence is provided to show that the services were provided outside the scope of the NP's State license. The Plan has not provided any evidence to support that this provider cannot be paid for the services at issue. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for the services provided on May 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you can't walk on your own and need therapy. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you are living at home and receiving home health services for weakness and functional decline. Your medical problems are stable and you have no identified problems that need inpatient medical management. You have no complex nursing or rehabilitation needs. You need physical and occupational therapy but do not require an intensive therapy program in an IRF. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehab in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).You asked the Plan to pre-approvethe service. You say that the service is necessary.The Plan denied yourrequest. The Plan says the service is not necessary.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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the safety and effectiveness of the Superion Interspinous Spacer has not been studied in patients with prior lumbar spine surgery. Superion indirect lumbar decompression would not be considered the standard of care for your medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of your medical condition.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 service have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of interlaminar/interspinousprocess stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit you had with a urologist on June 9, 2020.You asked the Plan to waive the copayment forthe urology visit. You say that you had to return to the doctor's office to have a stent removed, so this copayment should be waived.The Plan denied your request. The Plan says you were charged this copayment 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 visits with a specialist. You have been asked to pay a $40 copayment for the urology visit. The urology visit falls within specialist benefit category. This copayment applies regardless of the reason for the visit. 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 forthe office visit you had with a urologiston June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (G0483) provided on March 16, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says themedical records submitted only document 20 drugs tested. The Plan states that there is a more appropriate HCPCS (G0482) that should be used to bill for the service provided. It is noted 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 code.In this case, code G0483 is not supported by the records provided. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decidedthat the Plan does not have to pay forlab services (G0483) provided to the enrollee on March 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waivethe 20% coinsurance charged for durable medical equipment (compression sleeves) provided on August 7, 2020.You asked the Plan to waivethis coinsurance. You say that you have never had to pay for these before.The Plan denied your request. The Plan says this coinsurance was charged based on the item received and the 2020 Plan contract agreement.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment. 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 waivethe 20% coinsurance charged for durable medical equipment (compression sleeves) providedon August 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on July 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was obtained. The Plan says that the referring provider is also out-of-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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 forlab work provided on July 11, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe podiatry services provided on November 21, 2018.You asked the Plan to pay forthe podiatry services. You say that the original claim was submitted timely.The Plan denied your request. The Plan says the claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the podiatry services was not filed until May 12, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe podiatry services provided on November 21, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 11, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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 solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on June 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen (CPT Code J0885).
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says step therapy exceptions are made when: the member has had an inadequate
response to Retacrit, for at least two consecutive months, with appropriate dose adjustment; OR the member's
prescriber says why the member can't take Retacrit; OR that the member is already using the requested drug.
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 medication. Our physician reviewer
found the notes state that the member had failed Venofer (iron infusion). The provided notes show that the
member has not tried and failed Retacrit. Retacrit would not likely be less effective or have more adverse
effects for the member compared to Epogen use as these erythropoietin stimulating agents have essentially
equal effectiveness and safety based on current literature.
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 medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Epogen (CPT Code J0885).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Laminotomy (63030-AS-LT) provided on October 21, 2019.
You asked the Plan to pay for the Laminotomy. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says CPT 63030 has an MUE value of 1, but 2 units were billed.
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 63030 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the Laminotomy have not been met. Therefore, we decided that the Plan does not have to pay for the Laminotomy (63030-AS-LT) provided on October 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a left below the knee amputation. The enrollee's medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided on April 27, 2020, through May 20, 2020.You asked the Plan to pay forthe home health services. You say that you would like reconsideration because the HIPPS code billed is correct.The Plan denied your request. The Plan says the claim has been billed with an invalid HIPPS code.The Plan must follow Medicare rules. Medicare rules say that  providers must report services correctly.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, this claim has been billed with HIPPS code 1CHNS. Per CMS, as of December 31, 2019, this HIPPS code is no longer valid.Therefore, we decided that the Plan does not have to pay forhome health services provided on April 27, 2020, through May 20, 2020.