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

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 3, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection (20610) Injection, triamcinolone acetonide (J3301) provided November 16, 2020.
You asked the Plan to waive the copayment for the outpatient services. You say that you were not told that you would be charged for the second shot. You think you should have been told before you took the second shot. The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay $300 copayment for covered surgery provided in an outpatient hospital or ambulatory surgical center. The enrollee has been asked to pay $195.17 for the outpatient services. Since the total allowed amount was less than the $300 copayment amount, the lesser amount was applied towards your copayment. The outpatient services fall within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for arthrocentesis, aspiration and/or injection (20610) Injection, triamcinolone acetonide (J3301) provided November 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses deluxe frames (V2025) and the progressive
lenses (V2781).
You asked the Plan to pay for the deluxe frames and progressive lenses. You say that it has been more than two
years since you received new frames. The Plan denied your request. The Plan says your benefit is limited to
either new frames or new contact lenses every two years, and you received new contact lenses last year.
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 covers either frames or contact lenses once every 24 months. The Plan does not cover
progressive lenses.
We looked at the file and the Plan's rules. You received contact lenses the previous year, therefore you were not eligible to receive frames on this date of service. Based on this information, we decided that the Plan's rules for coverage of the deluxe frames and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses deluxe frames (V2025) and the progressive lenses (V2781).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 7, 2020.
You asked the Plan to pay for the home visit. You say that the physician depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the physician provided medically necessary services and the claim should be processed for payment. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 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 home visit provided by an out-of-network provider on December 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 and F2 and gene analysis.
You asked the Plan to pre-approve F5 and F2 and gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that genetic testing for the F2 and F5 genes are only covered for enrollees that are pregnant. We looked at the file and Medicare rules. Review of the file does not support that you are pregnant. Based on this information, we decided that Medicare rules for coverage of F5 and F2 and gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve F5 and F2 and gene analysis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your
request. The Plan says that you do not meet criteria for coverage of a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have
not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on October 26, 2020.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed a tooth extracted and were unable to receive the extraction without the exam. The Plan denied your request. The Plan says you had exceeded the frequency limitation under your dental plan.

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, oral examinations are limited to two per calendar year. The record shows that you received oral exams on June 4, 2020, and June 26, 2020, and your oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on October 26, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa (J7323). You say that you want the enrollee to be treated with this
drug. The Plan denied your request. The Plan says the health plan states the enrollee has not first tried and had
a contraindication or intolerance to Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc One.

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 Euflexxa (J7323). Our reviewer says
that the drug is not medically necessary. Our physician reviewer found the enrollee has tried Euflexxa in the
remote past with minimal improvement, but date was not given and per review of the medical records, the
enrollee has had no viscosupplementation or intraarticular steroid injection treatments within the year/past 365
days. There is no documentation provided indicating that the plan's required drug(s) 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 Euflexxa (J7323) have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an office visit for podiatry services to be provided out-of-network.

You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because the
member is still in the grace period to find in-network providers and she already had this appointment booked.
The Plan denied your request. The Plan says that there are in-network providers available who can render the
requested service.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the office visit have been met. Specifically, the Plan specifically states that the member can
continue seeing the providers they see now for 180 days. The record indicates that the member is still within
this 180-day period. Therefore, we decided that the Plan has to pre-approve an office visit for podiatry services
to be provided out-of-network.

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-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee is receiving acute care services. The enrollee is receiving continuous renal replacement therapy. Acute care services have not been denied by plan. The LTACH would not be providing services that are not available at the current facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended at this it. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on December 21, 2020.

You asked the Plan to waive the copayment for these services. You say that the services shouldn't have a copayment. The Plan denied your request. The Plan says the copayment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.

Review of the file shows that you received outpatient surgical services in the form of arthrocentesis on December 21, 2020. You have been asked to pay a $150 copayment for these services. These services fall within the Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility 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 the outpatient surgical services rendered on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair provided on August 7, 2020.

You asked the Plan to pay for the wheelchair. You say that your doctor refused to prescribe the wheelchair. The Plan denied your request. The Plan says you did not complete the necessary evaluations for approval.

The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under certain medical indications. 

We looked at the file and Medicare rules. The records do not show that an evaluation was done to show your home was adequate for the operation of the wheelchair. Based on this information, we decided that Medicare rules for coverage of the wheelchair have not been met. Therefore, we decided that the Plan does not have to pay for the power wheelchair provided on August 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Losartan Potassium 50mg tab, for the enrollee.

You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the requested drug is intended for patient "self-administration."

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Losartan Potassium 50mg
tab, for the enrollee.

Benefits for the medication 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested monitor. You say that you are unable to prick your fingers to check your glucose levels. The Plan denied your request. The Plan says the monitor is not covered for those who are not on multiple doses of insulin.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation does not indicate that you perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan has to pre-approve sacroiliac (SI) joint injections.

You asked the Plan to pre-approve sacroiliac (SI) joint injections. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not
medically necessary.

Plan follows Medicare rules. Medicare rules say that sacroiliac (SI) joint injections are covered for certain
indications.

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 sacroiliac (SI) joint injections. Our
reviewer says that the documentation does support that the requested services are medically reasonable and
necessary. Our physician reviewer found the enrollee has SI joint pain as well as facet related pain. The enrolee
has a spinal cord stimulator in place. The enrollee takes Zanaflex, Lyrica, and Percocet. The enrollee has failed
conservative therapy. The request is a standard diagnostic evaluation of the SI joint. The Plan's guideline used
is not evidence based. Therefore, the enrollee meets criteria for the requested 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 sacroiliac (SI) joint injections have been met. Therefore, we decided that the
Plan has to pre-approve sacroiliac (SI) joint injections.

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 drug testing services (G0482) provided on August 5,
2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted, The Plan denied your request. The Plan says the submitted claim form indicates the
laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation
and/or claim history indicates that the specimen was obtained in an office setting POS 11.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code G0482 is not supported in the record. Specifically, the claim was billed with a place of
service indicator indicating the specimen was collected in a laboratory setting. The documentation submitted
indicates that the member's face-to-face services were rendered in an office setting. Based on this information,
we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we
decided that the Plan does not have to pay for the drug testing services (G0482) provided on August 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol.

You asked the Plan to pre-approve Tramadol. You say that the enrollee has a lot of pain. The Plan denied your
request. The Plan says Tramadol to be taken at home is not covered under the Part B benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Tramadol.

Benefits for Tramadol may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.