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

We decided that the Plan does not have to pre-approve the hemochromatosis gene analysis.

You asked the Plan to pre-approve the hemochromatosis gene analysis. You say that you would like reconsideration because the requested testing is medically necessary. The Plan denied your request. The Plan says the record does not indicate any evidence of iron overload and the blood tests related to iron overload are normal.

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 hemochromatosis gene analysis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of iron overload and the blood tests related to iron overload are normal. There is no clinical rationale for the requested service. 

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 hemochromatosis gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve the hemochromatosis gene analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on April 7, 2021 by an OON provider.

You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that the treating provider did not advise you that they were OON and did not verify your insurance benefits. The Plan denied your request. The Plan says these services were rendered by a non-participating provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture (D5110) and complete mandibular denture (D5120) provided on April 7, 2021 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a specialist, ophthalmic imaging and corneoscleral lens contact fitting provided on March 3, 2021.

You asked the Plan to pay for an office visit, imaging and contact lens fitting. You say that you believe the charges for the scleral lenses should be covered as your doctor suggested it instead of surgery. The Plan denied your request. The Plan says this service is not covered by the Plan benefit and the service represents a capitated charge.

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 covers conventional or disposable contact lenses. The Plan contract does not cover this service or diagnosis. 

We looked at the file and the Plan's rules. The services at issue are not covered benefits of Medicare or the Plan. Based on this information, we decided that the Plan's rules for coverage of an office visit, imaging and contact lens fitting have not been met. Therefore, we decided that the Plan does not have to pay for an office visit with a specialist (99204), ophthalmic imaging (92133), and corneoscleral lens contact fitting (92313) provided on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 29, 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 payable.
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 enrollee 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 December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayment charged for specialist services provided on September 24, 2020.

You asked the Plan to waive this copayment. You say that you had a referral and should not have to pay this bill. The Plan denied your request. The Plan says this copayment was charged based on your Plan contract agreement for this type of physician visit.

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 $25 copayment for specialist visits.

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 $25 copayment charged for specialist services provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an out of network office visit on February 24, 2021.
You asked the Plan to pay for these services. You say that this office visit should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 an out of network office visit on February 24, 2021.
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 all services that would be provided in the LTACH are currently being provided in the acute care setting.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the inpatient rehabilitation services provided 
from July 8, 2020, to July 15, 2020. 
 
You asked the Plan to waive the copay for the services provided. You say that you were never told you would 
have to pay a copay for rehab. The Plan denied your request. The Plan says you have been asked to pay the 
correct amount based on your plan. 
 
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 
copay per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $325 copay per day for 5 days, totaling $1625. The services fall within the 
inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copay for the inpatient rehabilitation services provided from 
July 8, 2020, to July 15, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic pain from spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multi-level disease including moderate spinal stenosis at L3-L4 and L4-L5, the levels requested for treatment. The record does not indicate that surgical treatment at more than two levels is not required. The Superion spacer is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428) and ground mileage, (A0425) provided on February 26, 2021.
You asked the Plan to pay for the ambulance service. The Plan denied your request. The Plan says there is no claim or authorization on file to indicate the member was admitted to a skilled nursing facility.
The Plan contract says that authorization is required for non-emergency ambulance services.
We looked at the file and the Plan's rules. Based on this information, we decided that Medicare rules for coverage of the ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428) and ground mileage, (A0425) provided on February 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the surgical extraction (D7210) provided on November 19, 2020.
You asked the Plan to waive the cost share for the dental service. You say that this should be covered under your dental benefit. You say that this was an emergency procedure to prevent further damage. The Plan denied your request. The Plan says there is no supporting language to indicate alternate benefit will be applied for Class 3 Major Services. The Plan says that you are not responsible for the difference of the allowed amounts. The Plan also says there is a 50% coinsurance for Class 3 Major Services, including surgical extraction, after the $100 deductible has been met.
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, there is a 50% coinsurance for Class 3 Major Services, including surgical extraction, after the $100 deductible has been met. The record shows that the Plan reprocessed the claim and you are not responsible for the difference of allowed amounts. Therefore, we decided that the Plan does not have to waive the cost share for the surgical extraction (D7210) provided on November 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional PT visits.

You asked the Plan to pre-approve eight (8) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 eight (8) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that you have previously been treated with outpatient therapies and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of your medical condition and therefore are not 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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 30, 2021.
You asked the Plan to pay for the office visit. You say that you were advised you would have a $20 copay. The
Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. An office visit, when
provided by a chiropractor, is not a covered benefit. Therefore, we decided that the Plan does not have to pay
for the office visit provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided by the Rehabilitation Center from February 11, 2021, through March 12, 2021.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says that the record shows the enrollee received 100 days of SNF care during the benefit period from February 11, 2021 through March 12, 2021 and there was no 60-day period without inpatient hospitalization or skilled nursing facility care during that time.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. 

The file shows that the enrollee received more than 100 days of SNF care during the benefit period from June 6, 2020 through February 11, 2021 without 60 days in a row of inpatient hospital or SNF care. The Plan has covered more than 100 days of SNF care. 

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pay for SNF services provided from February 11, 2021 through March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on October 4, 2020.
You asked the Plan to pay for the neuromuscular stimulator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the documentation does not indicate that the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The documentation submitted did not indicate that the provider discussed the need for the billed supply code. This means the medical records do not contain sufficient documentation of the enrollee's medical condition to substantiate the necessity for the type of item provided. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator provided on October 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 0.25 mg luspatercept-aamt.

You asked the Plan to pre-approve the luspatercept. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet National Comprehensive Cancer Network recommendations.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the luspatercept. Our reviewer says that the requested use of luspatercept is not FDA approved for treatment of the member's condition. Our physician reviewer found the requested use is also not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.

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 luspatercept have not been met. Therefore, we decided that the Plan does not have to pre-approve 0.25 mg luspatercept-aamt.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the COVID-19 test (U0004) provided on August 12, 2020.
You asked the Plan to pay for the COVID-19 test. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the COVID-19 test (U0004) provided on August 12, 2020.