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

We decided that the Plan does not have to pay for drug testing services (80307, G0481) provided on July 15, 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 medical documentation and/or claim history indicates that the specimen was obtained in an office setting.

The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, this claim was submitted with a laboratory place of service code. The record indicates the member's face-to-face service was rendered in an office setting. There is a more appropriate place of service code for the services billed. Therefore, we decided that the Plan does not have to pay for drug testing services (80307, G0481) provided on July 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9612), the biologic materials to aid in soft and Osseous tissue regeneration (D4265), the unspecified preventive service (D1999), and the unspecified adjunctive service (D9999) provided on November 11, 2020.

You asked the Plan to pay for the therapeutic parenteral drug, the biologic materials, the unspecified preventive service, and the unspecified adjunctive service. You say that you have a Medicare Disability dental plan. You say that you were denied payment for services provided by an in network dentist. The Plan denied your request. The Plan says therapeutic parenteral drug is not listed as a covered service. The Plan says that the biologic material is not listed as a covered service. The Plan says that unspecified preventive service is not listed as a covered service. The Plan also says that unspecified adjunctive service is not listed as a covered service either.

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 are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the therapeutic parenteral drug (D9612), the biologic materials to aid in soft and Osseous tissue regeneration (D4265), the unspecified preventive service (D1999), and the unspecified adjunctive service (D9999) provided on November 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

You asked the Plan to pre-approve Aranesp. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 the medication is not medically necessary. Our physician reviewer found in this case, the enrollee has not tried and failed the required drug(s). 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hysteroscopy to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a hysteroscopy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 hysteroscopy to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit and chronic care management services provided on October 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the rest home visit and chronic care management services. 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 payable.

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 rest home visit and chronic care management services provided on October 26, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided from July 8, 2020, to July 14, 2020.

You asked the Plan to pay for home infusion therapy. You say that this should be covered. The Plan denied your request. The Plan says this was billed with an invalid code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code S9500 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9500) provided from July 8, 2020, to July 14, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 74 year old male currently in an inpatient rehabilitation facility (IRF). While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-pays for the outpatient infusion services provided from October 1, 2020, to October 12, 2020.

You asked the Plan to waive the co-pays for the infusion services. You say that the hospital agreed to charge you $150 a day for the infusions. The Plan denied your request. The Plan says there is no contract provision for waiver of this cost share.

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 $275 copay for each Medicare-covered outpatient hospital facility visit.

You have been asked to pay a $275 copay for each infusion service. The services fall within the outpatient hospital services 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 co-pays for the outpatient infusion services provided from October 1, 2020, to October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction services (92015) provided on December 4, 2020.

You asked the Plan to pay for the eye refraction. You say that you would like reconsideration because you were not aware that this service would not be covered. The Plan denied your request. The Plan says in order to be covered these services must be performed by a routine provider.

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 these services when performed by a routine vision care provider.

We looked at the file and the Plan's rules. The record indicates that this service was not rendered by a network provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for eye refraction services (92015) provided on December 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Gel-One injections provided on July 24, 2020.

You asked the Plan to waive the coinsurance for the Gel-One injections (J7326). You say that this coinsurance is a hardship. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Medicare Part B prescription drugs.

You have been asked to pay 20% coinsurance for the Gel-One injection (J7326). The Gel-One injections (J7326) fall within the Medicare Part B prescription drugs 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 the Gel-One injections provided on July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev 150mg capsule.

You asked the Plan to pre-approve Ofev 150mg capsule. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Ofev 150mg capsule.

Benefits for Ofev 150mg capsule 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cyclobenzaprine, 10mg tablet, and Hydrocodone-Acetaminophen, 5-325mg tablet, provided in an outpatient setting on May 28, 2020.

You asked the Plan to pay for the self-administered drugs. You say that you needed these drugs for your chronic spinal pain while you were visiting the emergency room. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received 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 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 pay for the Cyclobenzaprine, 10mg tablet, and Hydrocodone-Acetaminophen, 5-325mg tablet, provided in an outpatient setting on May 28, 2020.

Benefits for the self-administered drugs 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 the ConfirmMDx testing provided on November 5, 2020.

You asked the Plan to pay for the ConfirmMDx testing. 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 must follow Medicare rules. Medicare rules say that ConfirmMDx is only covered for certain indications.

We looked at the file and Medicare rules. Review of the file shows that the enrollee has not had a previous negative biopsy done in the last 24 months. Based on this information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on November 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo and Yervoy.

You asked the Plan to pre-approve Opdivo and Yervoy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drugs are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Opdivo and Yervoy. Our reviewer says that the documentation does not support that the requested drugs are medically reasonable or necessary. Our physician reviewer found the enrollee has metastatic microsatellite instability (MSI) colon cancer. The documentation shows that the enrollee has progressed on checkpoint inhibition; therefore, further checkpoint inhibition with Opdivo is unlikely to have benefit. Therefore, the requested drugs 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 Opdivo and Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo and Yervoy.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.

You asked the Plan to pre-approve SNF services. You say that you are not in a condition to be on your own. The Plan denied your request. The Plan says the evaluations do not support the need for daily skilled therapy or nursing.

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 physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are at a standby to minimal assist level for functional mobility. You require varying assist for activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an item purchased from an online retailer on November 13, 2020.
You asked the Plan to pay for an item purchased from an online retailer. You say that the requested item should be covered because all equivalent items from participating providers do not fit your face and are uncomfortable. The Plan denied your request. The Plan says rules for payment have not been met because the provider is not certified for Medicare.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, the items at issue were provided by a provider that appears to not be certified for Medicare. The provider at issue did not come up on the Medicare.gov search for durable medical equipment providers serving your area. There was no documentation supplied by the provider to verify that they are certified by Medicare. Therefore, we decided that the Plan does not have to pay for an item purchased from an online retailer on November 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for three computed tomography (CT) scans (70450, 71250, 74176) provided on September 18, 2020.

You asked the Plan to waive the copayment for three CT scans. You say that you have never been charged three copayments before. The Plan denied your request. The Plan says these services processed 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 $110 copayment for each Medicare-covered radiological diagnostic service. 

You have been asked to pay a $110 copayment for each of three CT scans, for a total responsibility of $330. 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 three computed tomography (CT) scans (70450, 71250, 74176) provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309) provided on October 19, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because there is no way to obtain authorization in a nursing facility setting. The Plan denied your request. The Plan says these services were not authorized.

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 nursing facility care (99309) provided on October 19, 2020 by an out of network (OON) provider.