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

We decided that the Plan has to pay for the Cologuard testing provided to the enrollee on April 11, 2019.
You asked the Plan to pay for the Cologuard testing. You say that this is a covered service. The Plan denied your request. The Plan says that a decision was not made within the time frame.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Cologuard testing is Medicare-covered service. The plan has not provided documentation showing that the coverage criteria for Cologuard testing have not been met. Without supporting documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the Cologuard testing provided to the enrollee on April 11, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
You asked the Plan to pre-approve Supartz FX. The Plan denied your request. The Plan says that they did not
receive documentation or medical records supporting the medical necessity for a step therapy exception.
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 Supartz FX. Our reviewer says that
Supartz FX is not medically reasonable and necessary for the enrollee in this case. The provided medical
records do not indicate that the enrollee has tried and failed the Plan's required drugs or that they would likely
be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the
enrollee's condition does not meet step therapy criteria for Supartz FX.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not
have to pre-approve Supartz FX for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 6, 2019.
You asked the Plan to pay for the laboratory services. 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 testing 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 provided on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, and prophylaxis provided on September 16, 2019.
You asked the Plan to pay for the bitewings, periodic oral evaluation, and prophylaxis. You say that when you signed up for this insurance a representative told you that you could go to any dentist because dental was not a Medicare covered expense. You also say that the Plan's website did not mention the dentists you could use. The Plan denied your request. The Plan says this provider had opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the rendering provider. This provider has opted out of the Medicare program. The file shows that this provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the bitewings, periodic oral evaluation, and prophylaxis provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for de-clotting infusion of implanted central venous access device or catheter (36593), an injection of alteplase recombinant (J2997), and irrigation of implanted venous access drug delivery device (96523) provided on August 8, 2019 to August 28, 2019 by the out of network provider.
You asked the Plan to pay for de-clotting infusion of implanted central venous access device or catheter, an injection, and irrigation of implanted venous access drug delivery device. You say that physician approved you to continue your weekly treatment for your medical condition with the physician. The Plan denied your request. The Plan says if you choose to go to a doctor outside the network, you must pay for these services yourself. If you need a type of service that cannot be provided by an in-network provider, you must obtain a prior authorization before getting the service. Your primary care physician (PCP) or in-network specialist or other provider will need to contact the Plan to obtain prior authorization. When the Plan contacted your medical group there was no authorization on file and your provider is out-of-network. No pre-authorization was found for a non-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 for de-clotting infusion of implanted central venous access device or catheter (36593), an injection of alteplase recombinant (J2997), and irrigation of implanted venous access drug delivery device (96523) provided on August 8, 2019 to August 28, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the spinal surgical procedure provided on
September 25, 2019.
You asked the Plan to reduce the copayment for the spinal surgical procedure. You say that you were told you
would have a $250 copayment. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for surgical services at an in-network outpatient hospital facility.
You have been asked to pay a $325 copayment for the spinal surgical procedure. The spinal surgical procedure
falls within the "Outpatient surgery, including services provided at 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 reduce the copayment for the spinal surgical
procedure provided on September 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray of the esophagus (74220) provided on September 18, 2019.
You asked the Plan to pay for the x-ray. You say that the member received multiple x-rays by separate providers on the same day. The Plan denied your request. The Plan says CPT code 74220 denied as the column II code to the Column I code 74245 and is not eligible for reimbursement.
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, we have confirmed that code the x-ray has a bundled relationship with code 74245 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray of the esophagus (74220) provided on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Teeter-FitSpine LX9 Inversion table purchased on August 7, 2019 by the out of network provider.
You asked the Plan to reimburse you for the inversion table. You say that you have tried other treatments and only the inversion table gives you results. The Plan denied your request. The Plan says you did not request prior authorization for the out-of-network supplier.
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 reimburse you 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. The medical record does not show you are unable to ambulate. We found no exception that would require the Plan to reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for the Teeter-FitSpine LX9 Inversion table purchased on August 7, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services.
You asked the Plan to pre-approve the physician's services. You say that you were told by the Plan that you could use the Plan's Convenience Care benefit to see this physician. The Plan denied your request. The Plan says the medical records we received from your healthcare provider did not show the Plan why you need to see a provider outside of your network for treatment.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 12, 2019. You asked the plan to pay for the x-ray. You say that the services were medically necessary and should be paid. The Plan denied your request. The Plan says the claim at issue is a duplicate of another claim already being processed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 71045 is not supported in the medical record. Specifically, the claim at issue here,
820192880476981, is a duplicate of claim 820192880475669 which is already being processed. Based on this
information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we
decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on September 16, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis
provided on September 16, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 9, 2019 to June 7, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 9, 2019 to June 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on September 4, 2019.
You asked the Plan to pay for the panoramic x-ray. You say that the Plan has paid for this service in the past. The Plan denied your request. The Plan says this service is not covered by your plan. The Plan also says that they confirmed that you were not enrolled in the supplemental Dental Platinum Rider in 2019.
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 panoramic x-ray provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit services provided on August 28, 2019 by the out of network provider.
You asked the Plan to pay for the hospital outpatient clinic visit. 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.
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 for the hospital outpatient clinic visit services provided on August 28, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0272) provided on September 17, 2019.
You asked the Plan to reimburse you for the dental services. You say that prior to your visit, you called and gave your insurance information to your dentist. You also say that since there was a mix up, you should be reimbursed for the dental services you received. The Plan denied your request. The Plan says the oral evaluation, prophylaxis, and bitewing x-rays are not covered when you receive them out of network. The Plan also says that the dentist in this case is an out of network dentist.
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 dental services you received are not covered when you receive them out of network. Therefore, we decided that the Plan does not have to reimburse you for the periodic oral evaluation (D0120), prophylaxis (D1110), and the bitewing x-rays (D0272) provided on September 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a virtual colonoscopy/CT colonography.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when 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 CT is not medically reasonable or necessary. Our physician reviewer found the submitted
documentation does not include a recent history or physical examination supporting previous colonoscopy
results, limitations to colonoscopy, or gastrointestinal complaints to support the requested study. Without the
support of the documentation, medical necessity cannot be determined.
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 not been met. Therefore, we decided that the Plan does not
have to pre-approve a virtual colonoscopy/CT colonography.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services you received from an out-of-network provider on June 28, 2019.
You asked the Plan to pay for the podiatry services. You say that you were told this would be covered. The Plan denied your request. The Plan says medical records were not provided.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider who rendered the services in question. Without records, it cannot be determined that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the podiatry services you received from an out-of-network provider on June 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crestor for the enrollee.
You asked the Plan to pre-approve Crestor. You say that the enrollee has taken this medication for a very long time. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Crestor for the enrollee.
Benefits for Crestor may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on August 6, 2018.
You asked the Plan to pay for the genetic testing. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for genetic testing provided on August 6, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on August 15, 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 code 81479-59 is not separately payable.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service. Specifically, the Plan approved BRCA1/BRCA2 genetic testing for the enrollee and the records do
not support that the BRCA1/BRCA2 testing billed with code 81479 was a separate and distinct procedural
service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59
modifier have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered to the enrollee on August 15, 2019.