Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve endovenous ablation of varicose veins for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says that the clinical information provided does not support medical necessity criteria for the
requested procedure.

The Plan must follow Medicare rules. Medicare rules say that services are covered if they are medically
necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found there is satisfactory documentation that the enrollee's symptoms are limited to the area intended for
treatment. There is satisfactory documentation of arterial perfusion. The symptoms are severe enough that they
impact her qualify of life and are associated with severe reflux in the territories to be treated. There is no
evidence of deep vein thrombosis, or other anatomic features that would complicate the planned procedure.
There is satisfactory documentation of efforts at conservative treatment. The proposed plan is both 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 the services have been met. Therefore, we decided that the Plan has to preapprove
endovenous ablation of varicose veins for the enrollee.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate lenses (V2784) and a miscellaneous vision item (V2799) provided on March 17, 2021, to March 24, 2021.

You asked the Plan to pay for polycarbonate lenses and a miscellaneous vision item. You say that you are confounded by the explanation that your optical frame allowance has been exhausted since you never submitted a claim for frames prior to this time. The Plan denied your request. The Plan says you exhausted the $150 allowance offered by your Plan.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says you have a $150 allowance, every 24 months, to use towards the purchase of eyewear. 

We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed benefit on March 17, 2021 and March 24, 2021. The records also show that you paid a total cost of $279.96 for your eyewear, which leaves you with a responsibility of $129.96 ($279.96 - $150 = $129.96). You submitted a claim for reimbursement and the Plan approved your maximum allowed benefit for eyewear. Based on this information, we decided that the Plan's rules for coverage of polycarbonate lenses and a miscellaneous vision item have not been met. Therefore, we decided that the Plan does not have to pay for polycarbonate lenses (V2784) and a miscellaneous vision item (V2799) provided on March 17, 2021, to March 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the genetic testing provided on December 10, 2020.

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary and urgently needed. You say this should be processed at the in-network level. The Plan denied your request. The Plan says that no prior authorization was obtained.

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. 

The enrollee was referred for the genetic testing by a contract provider. The file does not show that the plan provided notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the genetic testing provided on December 10, 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 pay for the laboratory services (0031U, 0032U, 81227, 81240, 81241, 81291, 81355, 81401, and 81479) provided on December 28, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (0031U, 0032U, 81227, 81240, 81241, 81291, 81355, 81401, and 81479) provided on December 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the closed treatment of nasal bone fracture without manipulation (21310) provided on January 7, 2021.

You asked the Plan to pay for code 21310. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 21310.

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 21310 is Closed treatment of nasal bone fracture without manipulation.

We find that CPT code 21310 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of closed treatment of nasal bone fracture without manipulation and therefore cannot be verified. Based on this information, we decided that Medicare rules for coverage of code 21310 have not been met. Therefore, we decided that the Plan does not have to pay for the closed treatment of nasal bone fracture without manipulation (21310) provided on January 7, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments for the transvaginal ultrasound (76830) and the pelvic ultrasound (76856) provided on October 14, 2020.

You asked the Plan to adjust the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $135 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic).

You have been asked to pay $229.14 ($114.57 copayment x 2) for the radiological diagnostic services provided. This amount is less than the applicable copayments for these services. 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 adjust the copayments for the transvaginal ultrasound (76830) and the pelvic ultrasound (76856) provided on October 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (G0483) provided on December 15, 2020.
You asked the Plan to pay for the laboratory services (G0483). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (G0483) provided on December 15, 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 the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section. 

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 your medical conditions are stable and you have no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be obtained in a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the testosterone cypionate injection (J1071) provided on September 29, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $.78 (Plan allowed amount of $3.90 x 20% coinsurance) for the Medicare Part B drug injection provided.
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 the testosterone cypionate injection (J1071) provided on September 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections. You say that the enrollee is in great need of this procedure and it will improve her daily living. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan approved two levels and only one to two levels are allowed per session per spine region.

The Plan follows Medicare rules. Medicare rules state that facet joint injections may be covered under certain circumstances. 

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 facet joint injections. Our reviewer says that this service is not medically necessary. Our physician reviewer found one to two levels, either unilateral or bilateral, are allowed per session per spinal region. Review of the records indicates that the enrollee does not meet the coverage indications for the requested additional facet joint injection. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you are unable to go places without these supplies. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Panzyga solution 30 mg/300ml for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there are no records showing a trial of the preferred drugs.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drugs. There is a statement from the provider that she is not capable of self-administering the subcutaneous Hizentra due to impaired visual acuity. However, there is no medical justification provided as to why the Privigen would likely be less effective and/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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Panzyga solution 30 mg/300ml for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Parkinson's Disease panel for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of how the results of the testing will impact treatment or management.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genetic testing with a Parkinson's Disease panel does not meet coverage criteria, as the testing will not directly impact treatment or management of the enrollee. There are no established therapies for Parkinson's disease that are based on genetic testing. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a Parkinson's Disease panel for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 77-year-old female recently treated for a urinary tract infection, hyponatremia, and anxiety. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. Finally, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 the service is medically necessary. The Plan denied your request. The Plan says the service 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 in the Medicare rules section. 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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 2, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 2, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on December 10, 2020.

You asked the Plan to pay for the genetic testing. You say that the service was medically necessary and urgently needed. You say this should be processed at the in-network level. The Plan denied your request. The Plan says that no prior authorization was obtained.

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. 

The enrollee was referred for the genetic testing by a contract provider. The file does not show that the plan provided notice that the genetic testing would not be covered. Under Medicare rules, this means the genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the genetic testing provided on December 10, 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.