Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the procalcitonin (PCT) services coded 84145 provided on June 25, 2019.
You asked the Plan to pay for the procalcitonin (PCT) services. 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 a covered benefit.
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 84145 is procalcitonin (PCT). We find that CPT code 84145 is not supported in the medical record. Specifically, the enrollee was inpatient for this date of service. The payment for this service is included in the part A DRG payment. Based on this information, we decided that Medicare rules for coverage of the procalcitonin (PCT) services have not been met. Therefore, we decided that the Plan does not have to pay for the procalcitonin (PCT) services coded 84145 provided on June 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a zoster (shingles) vaccine (90750) and administration (90471) provided on August 13, 2019. You asked the Plan to pay for a shingles vaccine and administration. You say that you should not have to pay for this. The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for a zoster (shingles) vaccine (90750) and administration (90471) provided on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta (J3304).
You asked the Plan to pre-approve Zilretta. You say that the requested medication is 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Zilretta. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on a review of the information submitted, this enrollee has already received left knee Zilretta injections. The authorization for repeat administration of Zilretta for the left knee cannot be provided. The documentation does not support that the service at issue is medically reasonable or necessary for this 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta (J3304).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9500) provided on January 24,
2020 to February 1, 2020.
You asked the Plan to pay for home infusion therapy. You say that this should be processed as in-network. 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 on
January 24, 2020 to February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided by a participating provider on January 22, 2020 to February 19, 2020.
You asked the Plan to waive the copayment for radiation therapy. You say that you were told this would cost $60. You say that you were not told it was $60 each time. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $60 copayment for outpatient diagnostic tests/radiation therapy. You have been asked to pay a $60 copayment for radiation therapy. The total amount you are being asked to pay is $1,140 ($60 x 19 visits = $1,140). The correct copayment has been applied to the services that were provided. Radiation therapy falls within the outpatient diagnostic tests/radiation therapy 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 radiation therapy provided by a participating provider on January 22, 2020 to February 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the occupational therapy evaluation provided on February 3, 2020.
You asked the Plan to waive the copayment for the occupational therapy evaluation. You say that you had surgery on your hand this day. You say that you didn't have the evaluation. The Plan denied your request. The Plan says the copayment 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 $40 copayment for Medicare covered occupational therapy visits.
You have been asked to a $40 copayment for the occupational therapy evaluation. The occupational therapy evaluation falls within the "Outpatient rehabilitation services" benefit category. The records show that the occupational therapy evaluation was performed. 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 occupational therapy evaluation provided on February 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical disc replacement with Mobi-C, associated
procedures, and hospital inpatient admission.
You asked the Plan to pre-approve cervical disc replacement with Mobi-C, associated procedures, and hospital
inpatient admission. 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. 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 cervical disc replacement with Mobi-C,
associated procedures, and hospital inpatient admission. Our reviewer says that the requested services are not
considered medically reasonable and necessary in this case. Our physician reviewer found you have
osteoporosis. This is a relative contraindication to cervical disc replacement surgery. Also, long term outcomes
of 2 level disc replacement remain poorly defined. The FDA approved the procedure for one level. You have
too many levels of degenerative disc disease (DDD) on imaging. Criteria is not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of cervical disc replacement with Mobi-C, associated procedures, and hospital
inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve
cervical disc replacement with Mobi-C, associated procedures, and hospital inpatient admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on July 30, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration because this service was medically necessary. The Plan denied your request. The Plan says the chest x-ray was reported with a non-covered diagnosis and should not be performed for screening purposes.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the chest x-ray, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on July 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided on December 1, 2019 through December 3, 2019.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the required modifier information has not been billed appropriately.
The Plan must follow Medicare rules. Medicare rules say that he claim must include the GN, GO or GP modifier to distinguish the discipline of the plan of care under which the service is delivered: We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Specifically, the submitted claim does not include the required modifier. Therefore, we decided that the Plan does not have to pay for outpatient services provided on December 1, 2019 through December 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal x-rays (72070 and 72100) and a pelvic x-ray (72170) provided on October 29, 2019. You asked the Plan to pay for the x-rays. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate to report a procedure both as a global service and as the technical or professional components. 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 codes 72070, 72100 and 72170 are not supported in the record. Specifically, the record indicate that these services were billed and paid globally. It is inappropriate to bill a procedure both as a global service and as the technical or professional components. Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. Therefore, we decided that the Plan does not have to pay for spinal x-rays (72070 and 72100) and a pelvic x-ray (72170) provided on October 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0480 provided on October 3, 2019.
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 G0480 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; 1-7 drug class(es), including metabolite(s) if performed.
We find that CPT code G0480 is not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed or what panel was requested. 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 G0480 provided on October 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is lack of evidence to support the device as a safe and effective treatment for lumbar spinal stenosis.
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 requested services. Our physician reviewer found that the requested device remains experimental. More research is needed to show safety and efficacy. Therefore, the requested device is not considered medically reasonable and 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 3, 2020 to January 27, 2020 by an out of network (OON) provider.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not a covered benefit.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 3, 2020 to January 27, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe skilled nursing facility (SNF) care provided from December 5, 2019 to December 23, 2019.You asked the Plan to waive the copayment forthe SNF care. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received SNF care on the dates of service at issue in this appeal. The Plan says the correct copayment has applied per your contract with the 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 $0 copayment for days 1 through 20, a $160 copayment for each day for days 21 through 44 in a network SNF, and from day 45 onward, the enrollee pays nothing for remaining covered days. We looked at the file, the Plan's contract and Medicare rules. The file shows you were admitted to SNF from September 9, 2019 to October 4, 2019. The first 20 days (September 9, 2019 to September 28, 2019) applied a $0 copayment. Dates of service from September 29, 2019 to October 4, 2019 applied a $160 per day copayment, totaling $800 for days 21-25. You were also admitted to SNF from December 5, 2019 to December 23, 2019, days 26 to day 43, applied a $160 per day copayment for 18 days, totaling $2880. However, only $879.21 applied to your copayment because with this amount you reached your out of pocket maximum for the 2019 benefit year. The SNF care falls within the Skilled nursing facility 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 copayment forthe skilled nursing facility (SNF) care provided from December 5, 2019 to December 23, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).
You asked the Plan to pre-approve Hyalgan. You say that Hyalgan is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Hyalgan. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the record does not show a trial of the plan preferred agents or any reason why they would be contraindicated for this 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forgym fees on November 1, 2019 for a non-participating fitness facility.You asked the Plan to pay forthe services. You say that you submitted a request for reimbursement for gym fees you paid in November 2019 for an out-of-network fitness center membership feeThe Plan denied your request. The Plan says this reimbursement is not approved.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because you are only allowed reimbursement towards one participating gym membership OR non-participating membership and cannot be reimbursed for both.Therefore, we decided that the Plan does not have to pay forgym fees on November 1, 2019 for a non-participating fitness facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prophylaxis and periodic oral evaluation provided by an OON provider on July 29, 2019.You asked the Plan to pay forthe prophylaxis and periodic oral evaluation. You say that you were not notified that this provider was no longer in-network with your plan.The Plan denied your request. The Plan says these services were rendered by a non-contracted 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.Thoughthe 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 forthe prophylaxis and periodic oral evaluation provided by an OON provider on July 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy.
The Plan must follow Medicare rules. 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 the drug. 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 the review has determined that the plan requires a trial of Epoetin Alfa before they will approve the requested drug. The review has determined that the patient has not tried and failed the required drug(s). The plan's required drug(s) is not likely to be less effective and/or likely have adverse effects for the enrollee. The accepted use of this drug for the enrollee's illness requires the hemoglobin level prior to initiation of ESA treatment is less than 10 g/dL (or the hematocrit is less than 30%). 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp (J0881) for the enrollee.