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

We decided that the Plan does not have to waive the cost-share for the diagnostic imaging services (78452,
93306, 93880, 93923, 93970) and tetrofosmin (A9502), and the office visit with a specialist (99214).

You asked the Plan to waive the cost-share for the diagnostic imaging services and supplies and office visit.
You say that you do not want to pay this cost-share amount. The Plan denied your request. The Plan says this
cost-sharing is part of your insurance agreement and was applied correctly to these claims.

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 $110
copayment for each Medicare-covered radiological diagnostic service, 20% coinsurance for each Medicarecovered
medical supply, and a $30 copayment for an office visit with a specialist.

You have been asked to pay $581.11 for the services. On this date, you received a myocardial perfusion imaging, tomographic (SPECT) study (78452), an ultrasound of the heart (93306), a duplex scan (ultrasound) of the extracranial arteries (93880), an ultrasound of the arteries in both arms and legs (93923), a duplex scan (ultrasound) of the veins in the arms and legs (93970) and tetrofosmin (A9502) which is a drug used in one or more of these imaging processes.

Ultrasounds and SPECT studies fall within the radiological diagnostic services category, and therefore are each
subject to a $110 copayment ($110 x 5 diagnostic imaging services = $550). Tetrofosmin is a medical supply
and requires 20% coinsurance. The Plan's allowed amount for tetrofosmin (the amount the Plan has agreed to
let the provider be paid) is $222.20. You were asked to pay $44.44 ($222.20 x 20% = $44.44). The total cost
share you have been asked to pay is less than the amount the Plan allows for these services ($550 + $44.44 =
$594.44). This means that you have been asked to pay the correct amount for the services provided, based on your contract with the Plan.

You have also been asked to pay a $30 copayment for the office visit with a specialist on October 30, 2020. An
office visit with a specialist is subject to a $30 copayment. This means that you have been asked to pay the
correct amount for this service 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 cost-share for the diagnostic imaging services (78452, 93306,
93880, 93923, 93970) and tetrofosmin (A9502), and the office visit with a specialist (99214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (personal protective equipment).

You asked the Plan to pay for the personal protective equipment. You say that you would like this service to be covered. The Plan denied your request. The Plan says this service is not covered. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.

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 preventive procedure (personal protective equipment).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endoskeletal system, below knee, alignable system
(L5910).

You asked the Plan to pre-approve endoskeletal system, below knee, alignable system. You say that the item is
medically necessary. The Plan denied your request. The Plan says the alignable system is not reasonable and
necessary for a preparatory prosthesis.

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 endoskeletal system, below knee,
alignable system. Our reviewer says that the requested item is not considered medically reasonable and
necessary in this case. Our physician reviewer found that an alignable system cannot be used with a preparatory
prosthesis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of endoskeletal system, below knee, alignable system have not been met.
Specifically, you have been approved for a preparatory prosthesis. An alignable system is not needed for a
preparatory prosthesis. This means the item is not medically necessary or reasonable. Therefore, we decided
that the Plan does not have to pre-approve endoskeletal system, below knee, alignable system (L5910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.

The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described above.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a pelvic and sacral fracture after a fall. Her medical problems are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record documents a need for physical and occupational therapy but not for an intensive rehabilitation program. Medically necessary services could be provided in a low level of care.

There is a not reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel injections, 50mg/ml.

You asked the Plan to pre-approve Enbrel. You say that the enrollee has been on Enbrel therapy. You also say that discontinuation of this therapy could have adverse effects. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan also says that self-administered drugs are not covered under Medicare 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 drug 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 Enbrel injections, 50mg/ml.

Benefits for Enbrel 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient dialysis services.

You asked the Plan to waive the coinsurance for dialysis. You say that you had reached your out-of-pocket maximum, and should not have to pay any more for these services. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for dialysis services. At the time this claim was processed, $6,281.18 of the $6,700 maximum out-of-pocket amount had been met. The allowed amount of the claim is $5,427.63, resulting in a coinsurance obligation of $418.82 because this amount - along with other cost-sharing you have been asked to pay - met the $6,700 maximum out-of-pocket amount.

You have been asked to pay 20% coinsurance for dialysis. Dialysis falls within the Services to Treat Kidney Disease 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 coinsurance for outpatient dialysis services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 the medical services provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis.

You asked the Plan to pay for these services. You say that you were unable to submit this claim because of an illness. The Plan denied your request. The Plan says that the claim was not submitted timely and was processed correctly.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until October 9, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the extracapsular cataract removal with insertion of intraocular lens prosthesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dutasteride-tamsulosin.

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 self-administered drugs are not covered.

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 dutasteride-tamsulosin.

Benefits for these services 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 procedure code 27130 is not supported.

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 27130 is arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. 

We find that CPT code 27130 is not supported in the medical record. Specifically, there is no documentation of total hip arthroplasty with or without autograft or allograft. 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 pay for the surgical services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (KO), single upright, thigh and calf, w adjustable flexion and extension joint (L1851) and suspension sleeve (L2397).

You asked the Plan to pay for knee orthosis and suspension sleeve. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted is insufficient.

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 pay for knee orthosis and suspension sleeve. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthosis and suspension sleeve have not been met. Specifically, there is insufficient documentation to confirm the medical necessity of the items requested. Therefore, we decided that the Plan does not have to pay for knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (L1851) and suspension sleeve (L2397).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.

We looked at the file and Medicare rules. The file shows that one unit of code 71045 was previously paid by the Plan on a separate claim for the same date of service. There is no documentation to support further units of this code. 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 pay for the chest x-ray.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services.

You asked the Plan to pay for the paramedic intercept services. You say that you should not be billed for these services. The Plan denied your request. The Plan says that there is no agreement between the ALS and BLS ambulance providers.

The Plan must follow Medicare rules. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services.

The Plan has confirmed that the ambulance company does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services.

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 procedure code 95999 is not supported.

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 95999 is unlisted neurological or neuromuscular diagnostic procedure.

We find that CPT code 95999 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. 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 pay for the testing services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (darbepoetin alfa).

You asked the Plan to pre-approve Aranesp. You say that Aranesp is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested drug does not meet the Plan's medical necessity guidelines for coverage. The Plan says there is no indication that Retacrit would be less effective or cause adverse effects for the enrollee.

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 Aranesp. Our reviewer says that Aranesp is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Retacrit for at least 2 consecutive months, with appropriate dose adjustment, before they will approve the requested drug. The reviewer found that in this case, the enrollee has not tried and failed the required drug. The reviewer found that there is no documentation provided that indicates the required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug is not medically reasonable or 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp (darbepoetin alfa).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion with an out-of-network general
surgeon.

You asked the Plan to pre-approve the referral. You say that you have a rare breast cancer called secretory
carcinoma. The Plan denied your request. The Plan says these services are not an emergency.

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 care that cannot be provided by network providers.

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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a second opinion with an out-of-network general surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the enrollee's care can be provided in the current inpatient hospital.

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 the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.