Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to hold you harmless for the denied genetic tests. We decided that the Plan does not have to waive the coinsurance for genetic tests.
You asked the Plan to pay for and waive the coinsurance for genetic tests. You say that you paid a copayment at the office visit and have never had to pay an extra amount before. The Plan says that the denial of payment for testing is correct, because you received the denied tests in the past and repeat testing was not justified. The Plan also says that the coinsurance amount you are being charged is correct.
We decided that the Plan has to hold you harmless for the denied genetic tests with testing codes 81225 and 81226.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.
You were referred for genetic tests by an in-network provider. The file does not show that the Plan provided notice that genetic tests would not be covered. Under Medicare rules, this means genetic tests are considered approved by the Plan. The Plan must ensure that you are not held liable for the non-covered amounts billed by this in-network provider, which total $379.81. Therefore, we decided that the Plan has to hold you harmless for the denied genetic tests.
We also decided that the Plan does not have to waive the coinsurance for genetic tests.
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 in-network genetic tests. The allowed amount of the approved tests is $249, resulting in a coinsurance obligation of $49.80. Therefore, we decided that the Plan does not have to waive the coinsurance for genetic tests.
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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pain related to bilateral knee osteoarthritis, confirmed with x-rays. She has failed conservative treatment. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be less effective or contraindicated; therefore, Durolane is not reasonable or medically necessary at this time. 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 Durolane.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that on the date of service you called 911 for the enrollee because of an emergency situation. You say that an ambulance and police were sent to the enrollee's home. You stated that the EMT responders looked at the enrollee but did not provide any emergency services. You say that the enrollee chose to go with the police to the hospital instead of the ambulance. You stated that the enrollee has sustained a great loss of income with having to move and you asked the Plan to reconsider providing coverage for the services.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 5, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on December 5, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you are asking the Plan to pay this claim. The Plan denied your request. The Plan says you have been charged thecorrect 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 $265 copayment per date of services regardless of the number of trips for an in-network ground ambulance. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 forthe ambulance transport provided on December 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee does
not meet the requirements for approval of an IRF admission. The enrollee can safely receive the services in
other settings, for example: a skilled nursing facility, home with home health and home physical therapy, or
home with outpatient therapy.
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. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's
current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may
benefit from additional multiple therapies, however the enrollee's functional level which is noted to be limited
due to fatigue and poor endurance does not require or indicate that she can tolerate this therapy in an IRF with
an intensive level program.
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 an IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on December 17, 2019.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 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 test at issue in this appeal, the genetic testing, 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 genetic testing provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe tendon sheath injection provided on January 16, 2020.You asked the Plan to waive the copayment forthe tendon sheath injection. You say that you only had one shot in your foot. You say that you want to know why you're getting billed for that amount.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 andcoinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay $240.56, which is less than the standard$250 copayment for the tendon sheath injection. The tendon sheath injectionfalls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forthe tendon sheath injection provided on January 16, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the copayment forthe colonoscopy provided on May 15, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that there is no copayment, coinsurance, or deductible for a screening colonoscopy.The Plan denied your request. The Plan says that 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 enrollees have no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. The Plan says you must pay a $40 copayment for the colonoscopy. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the colonoscopy.The record shows a diagnosis code for a malignant neoplasm screening.This means that there is no evidence that this colonoscopy was ordered for diagnostic purposes or that any polyps were removed during this colonoscopy.Therefore, we decided that the Plan has to waive the copayment forthe colonoscopy provided on May 15, 2019.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denialThe Plandenied your request. The Plan says the requested admission is 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 ourphysician 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. Our physician reviewer found the enrollee required moderate assistance for bathing. The enrollee required maximum assistance with dressing. The enrollee required minimal assistance times two for toilet transfers, standing up, and sitting down. The documentation does not support that the enrollee requires the intensity of services provided at an IRF. The documentation does not support that the enrollee is able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower 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 IRFcare have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Linx procedure (CPT 43284) for the enrollee. You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered service. The Plan must follow Medicare rules. Medicare rules say that CPT 43284 is not a covered code. The requested procedure is coded with CPT 43284. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Linx procedure (CPT 43284) for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a chest x-ray (71046) provided on January 24, 2020.
You asked the Plan to pay for a chest x-ray. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says that this claim was submitted with incomplete diagnosis 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. We find that CPT code 71046 is supported in the record. Specifically, the record indicates that this service was for a preoperative examination and not for the purpose of diagnosis or treatment. Based on this information, we decided that Medicare rules for coverage of a chest x-ray have been met. Therefore, we decided that the Plan has to pay for a chest x-ray (71046) provided on January 24, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit injections (Q5106), administration, and treatment.
You asked the Plan to pre-approve Retacrit, administration, and treatment. The Plan denied your request. The Plan says Retacrit is not medically necessary at this time. The Plan also says that the Plan's prior authorization coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Retacrit. Our reviewer says that Retacrit is not medically reasonable and necessary. Our physician reviewer found the use of Retacrit is supported by the Food and Drug Administration label and the compendia when the hemoglobin is less than 10. The enrollee's hemoglobin was 10.8 on testing done on June 2, 2020. Our reviewer found that the submitted documentation does not indicate that the enrollee has had transfusions. Our physician reviewer also found that the documentation does not support that the use of Retacrit is medically reasonable and necessary or safe and effective 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit injections (Q5106), administration, and treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xgeva and Docetaxel. You asked the Plan to pre-approve Xgeva and Docetaxel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee has not met step therapy criteria. 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 Xgeva and Docetaxel. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the submitted documentation does not indicate that the enrollee has been treated with either Pamidronate or Zoledronic acid. The NCCN Guidelines Version 6.2020 Non-small cell lung cancer page NSCL-17 lists both bisphosphonates (Pamidronate and Zoledronic acid are bisphosphonates) and Denosumab (Xgeva) as options to treat bone metastasis without prioritizing their use. The documentation does not support that the preferred agents are likely to be less effective or have more adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Xgeva and Docetaxel have not been met. Therefore, we decided that the Plan does not have to pre-approve Xgeva and Docetaxel.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCyramza.You asked the Plan to pre-approveCyramza. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically 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 Cyramza. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has IV gastric cancer. The requested use of Cyramza is only FDA approved in combination with a taxane or as monotherapy. While the documentation supports that the requested drug is safe and effective for the enrollee, it is not in combination with Folfiri. For gastric cancer, the indication is for monotherapy or in combination with a taxane. Therefore, the enrollee does not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cyramza have not been met.Therefore, we decided that the Plan does not have to pre-approveCyramza
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the patient educational materials rendered on November 11, 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 the services are not separately payable.The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified.We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99071. This code has a status indicator of B and no separate Medicare payment.Therefore, we decided that the Plan does not have to pay for the patient educational materials rendered on November 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNFservices.You asked the Plan to pre-approve the SNF services. You say that you are not in hospice and the SNF services should be approved for continued management of your injury. The Plan denied your request. The Plan says you are enrolled in a Federal Medicare-certified hospice program, which will be revoked on July 11, 2020.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. You are under the Medicare hospice benefit for the dates of service at issue in this appeal. The SNF services being requested are before the end of the month of the hospice revocation date. Therefore, we decided that the Plan does not have to pre-approve SNFservices.
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 intensive physical therapy and occupational therapy are medically necessary for the enrollee to increase independence and to return to the prior level of function. You say that the enrollee meets the criteria for admission. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another setting.
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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. 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.