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

We decided that the Plan does not have to pay for physician's services provided on August 26, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on August 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on August 31, 2020.You asked the Planto waive the copayment for lab work. You say that you do not agree with this copayment for lab work. 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 $10 copayment for outpatient diagnostic tests/laboratory tests/in-network. You have been asked to pay a $10 copayment for lab work. The correct copayment has been applied to the lab work that was provided. Lab work falls within the outpatient diagnostic tests/laboratory tests/in-network 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 lab work provided by a participating provider on August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiotherapy (PBRT) for treatment of
prostate cancer.
You asked the Plan to pre-approve the PBRT. You say that PBRT would be the best option to reduce radiation
exposure to normal cells. The Plan denied your request. The Plan says there is not sufficient evidence to
support that PBRT is superior to IMRT.
The Plan follows Medicare rules. Medicare rules say that PBRT for prostate cancer may be covered only when
the specific criteria listed above are met.
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 PBRT. Our reviewer says that the
requested PBRT is not considered medically reasonable and necessary and does not meet LCD criteria. Our
physician reviewer found whether proton therapy for prostate cancer affords any advantage over intensitymodulated
radiation therapy (IMRT) is very controversial. Most reports, including a systemic review conclude
that patients treated with proton therapy fare comparably and/or better to patients treated with photon radiation
(i.e. IMRT). Various studies call into question whether PBRT for prostate cancer in fact reduces radiation
toxicity to the rectum. There are also studies that show very little reduction in secondary, radiation-associated
malignancies between IMRT and PBRT.
Nothing in the case file suggests that necessary dose constraints to normal tissues cannot be met with the nonproton-
based treatment, and it is not plausible that proton therapy would be needed to meet these constraints.
Proton therapy will almost always reduce dose to surrounding normal tissues. Simply demonstrating that proton
therapy will reduce the low dose to normal tissues does not necessarily demonstrate that it is clinically needed
relative to IMRT though, as the reductions should be clinically meaningful, and reduce toxicity risks in a
clinically meaningful manner, which is not clearly demonstrated. As IMRT is shown to be able to safely deliver
therapeutic radiation doses to the prostate without exceeding dose constraints to normal tissues, the criteria for
this treatment are 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 the PBRT have not been met. Therefore, we decided that the Plan does not have
to pre-approve proton beam radiotherapy (PBRT) for treatment of prostate cancer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require 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 did not pre-approve the
physician's services. We found no exception that would require the Plan to pay for these services. Therefore,
we decided that the Plan does not have to pay for physician's services provided on February 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CGX Comprehensive Cancer Panel provided to the enrollee on June 11, 2019.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary. Our physician reviewer found that the enrollee is a 74-year-old man with listed diagnoses of Personal history of malignant neoplasm of breast, Family history of malignant neoplasm of digestive organs, and Family history of malignant neoplasm, unspecified. The case file contains the results of the CGX Comprehensive Cancer testing. There are no clinical records for review. The clinical documentation is limited, and does not support that a CGX Comprehensive Cancer Panel was medically reasonable and necessary for the enrollee in this case.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 testing have not been met.Therefore, we decided that the Plan does not have to pay forthe CGX Comprehensive Cancer Panel provided to the enrollee on June 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvethe requested device. The Plan denied your request. The Plan says coverage criteria have not been satisfied.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for certain medical indications.We looked at the fileand Medicare rules. The documentation does not indicate that the enrollee performsblood glucose testing at least four times per day, usesinsulin with at least three daily injections, orrequiresfrequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveOON services. You say that it'sin your best interest to continue with this therapist.The Plan denied your request. The Plan says you must receive your care from a network provider.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 physical therapy services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approvephysical therapy services to be provided by an out of network (OON) provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean OmniSequ Comprehensive Panel.You asked the Plan to pre-approvean OmniSequ Comprehensive Panel. You say that the requested testing is medically necessary.The Plan denied your request. The Plan says the guidelines for coverage have 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 an OmniSequ Comprehensive Panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a diagnosis of malignant neoplasm of the prostate. The enrollee's oncologist writes that the enrollee has metastatic prostate cancer with an unusual collection of 3 different histologies -adenocarcinoma the prostate, ductal carcinoma, and carcinosarcoma. It is currently the adenocarcinoma the prostate that is most active. The enrollee has received and ultimately failed all the standard hormonal therapies and has received a number of chemotherapies over the years targeting either the sarcomatous component or the adenocarcinomatous component of his cancer. The enrollee is currently on Cabazitaxel. The documentation does not support that the enrollee has non-small cell lung cancer or metastatic colorectal cancer and is a candidate for intensive chemotherapy with an anti-EGFR biologic agent.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an OmniSequ Comprehensive Panel have not been met.Therefore, we decided that the Plan does not have to pre-approvean OmniSequ Comprehensive Panel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on March 6, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $91.29. The total amount you are being asked to pay is $18.26 ($91.29 x 20% = $18.26). An injection falls 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 an injection provided by a participating provider on March 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Purewick female external catheter.You asked the Plan to pre-approvea Purewickfemale external catheter. 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 other supplies used in the management of incontinence will be denied as non-covered because they are not prosthetic devices nor are they required for the effective use of a prosthetic device.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Purewick female external catheter have not been met.Therefore, we decided that the Plan does not have to pre-approvea Purewick female external catheter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon November 9, 2020.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services providedon November 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea revision surgery to be provided by an out of network provider.You asked the Plan to pre-approvea revision surgery with an out of network provider. You say thatyou want the orthopedist who did the surgery to do the revision surgery.The Plan denied your request. The Plan says the requested provider is out of network and you are approved to see an in network orthopedic surgeon.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvea revision surgery to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ankle orthosis coded L1902 provided on August 31, 2020.You asked thePlan to pay forthe ankle orthosis. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services were billed incorrectly.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 L1902 is ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf.We find that CPT code L1902 is not supported in the medical record. Specifically, this code was billed with modifiers RT (right side) and KX (requirements specified in the medical policy have been met) and with diagnosis code M25.579 (Pain in unspecified ankle and joints of unspecified foot). Diagnosis code M25.579 is not specific to the Right side; however, code L1902 is appended with modifier RT indicating the right side. Code L1902 should be billed with a more appropriate diagnosis code. Based on this information, we decided that Medicare rules for coverage of the ankle orthosis have not been met.Therefore, we decided that the Plan does not have to pay forthe ankle orthosis coded L1902 provided on August 31, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for Observation Services provided on September 4, 2020.
You asked the Plan to adjust the copayment for Observation Services. You say that you should only have a $90 emergency care copayment. The Plan denied your request. The Plan says you had a covered Observation Stay so you were charged the copayment 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 $225 copayment for outpatient hospital observation. You have been asked to pay a $225 copayment for Observation services. Observation services falls within the outpatient hospital observation 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 adjust the copayment for Observation Services provided on September 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBrilinta.You asked the Plan to pre-approveBrilinta. You say that this is a superior medication.The Plan denied your request. The Plan says this drug is 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 pre-approveBrilinta.Benefits for Brilintamay be available under Medicare Part D.Contactthe 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 pay forthe services provided on June 11, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the claim was submitted after the timely filing limit.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 afterthe date of service.The record shows that a claim for the services was not filed until August 31, 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 forthe services provided on June 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit (99204, 92504) provided on September 15, 2020.You asked the Plan to waive the copayment fora specialist office visit. You say that this should be covered.The Plan denied your request. The Plan says this 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 $40 copayment for visits to specialists. You have been asked to pay a $30.03 copayment for a specialist office visit because the allowed amount is less than $40. 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 fora specialist office visit (99204, 92504) provided on September 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on June 17, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim should be submitted to Original Medicare.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 forphysician services provided to the enrollee on June 17, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fecal occult blood test you received on October 27, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this service is covered
once every 12 months.
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 one fecal occult blood
test is covered every 12 months.
Based on review of the file, a fecal occult blood test was provided less than 12 months prior to the testing at
issue in this case. Therefore, we decided that the Plan does not have to pay for the fecal occult blood test you
received on October 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment forcomputed tomography, head or brain (70450) and echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93306) provided August 14, 2020.You asked the Plan to waive the deductible and copayment forthe diagnostic services. You say that you hereby appeal your share of the costs.The Plan denied your request. The Plan says the claim was processed and the deductible and correct copayments was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible and $160 copayment for each radiological diagnostic service not including x-rays, performed in a physician's office or at a free standing facility, such as a radiology center or medical clinic. You have been asked to pay $1,320 ($1,000 deductible + $160 + $160) for the diagnostic services. You have a $1000 deductible. This is the amount you must pay out of pocket before the plan will pay their share. The diagnostic servicesfall within the benefit category Outpatient diagnostic tests andtherapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the diagnostic services was received on August 14, 2020.Therefore, we decided that the Plan does not have to waive the deductible and copayment forcomputed tomography, head or brain (70450) and echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed (93306) provided August 14, 2020.