Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve radiopharmaceutical localization of a tumor.
You asked the Plan to pre-approve radiopharmaceutical localization imaging. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this testing is correct, because this test is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 radiopharmaceutical localization imaging. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the requested imaging study can be highly specific for cardiac amyloidosis and may be sufficient for confirming the diagnosis without the need for tissue biopsy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiopharmaceutical localization imaging have been met. Therefore, we decided that the Plan has to pre-approve radiopharmaceutical localization of a tumor.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 30, 2020 by a non-network 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 a non-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 referring provider 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 laboratory services provided on November 30, 2020 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81407) provided on October 28, 2020.
You asked the Plan to pay for a comprehensive cardiovascular panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular panel (81407) provided on October 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the diagnostic testing and injection services provided on December 11, 2020.

You asked the Plan to waive the cost shares for the services provided. You say that you should not be charged for additional tests when you go in for an office visit. The Plan denied your request. The Plan says the cost share was applied per plan benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

The file shows that you received a dexamethasone injection. You were charged a 20% coinsurance. The services fall within the Medicare Part B prescription drugs benefit category. You also received respiratory flow testing. You were charged a $20 copay. The services fall within the outpatient diagnostic tests 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 cost shares for the diagnostic testing and injection services provided on December 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit and electrocardiogram services provided on September 25, 2018.
You asked the Plan to pay for the emergency department visit and electrocardiogram services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim was filed untimely.
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 the emergency department visit and electrocardiogram services was not filed until October 5, 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 emergency department visit and electrocardiogram services provided on September 25, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required provided on November 24, 2020.
You asked the Plan to pay for the core buildup. The Plan denied your request. The Plan says this service is not covered.
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 core buildup, including any pins when required provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of single or dual chamber pacing defibrillator leads.
You asked the Plan to pre-approve insertion or replacement of single or dual chamber pacing defibrillator leads. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 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 insertion or replacement of single or dual chamber pacing defibrillator leads. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are no medical records indicating titration of medications to highest tolerated doses with subsequent reassessment of left ventricular ejection fraction (LVEF) at 3 months of this therapy and subsequent documentation of ejection fraction as less than 35%, to make an ICD indicated based on the ACC/AHA published criteria. In the absence of documentation of this previous guideline directed plan of care and subsequent appropriate LVEF reassessment, the ICD insertion does not meet the applicable CMS section 1862(a)1(A) medical necessity criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion or replacement of single or dual chamber pacing defibrillator leads have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion or replacement of single or dual chamber pacing defibrillator leads.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 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 you do not require skilled nursing and/or
skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a
lower level of care. Although further rehab services would be appropriate to improve function, as a practical
matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility.
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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for FoundationOne Liquid CDx testing provided on October 21, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and the enrollee met all of the coverage requirements. The Plan denied your request. The Plan says that this testing is not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for genetic testing by a contract provider. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for FoundationOne Liquid CDx testing provided on October 21, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5257 x2) received June 10, 2020.
You asked the Plan to pay for the hearing aids. You say that the Plan should pay for the hearing aids. The Plan denied your request. The Plan says the provider in this case is not in the Plan's network.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased through an in-contract provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5257 x2) received June 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on December 10, 2020.
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 was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that POS code 21 must be billed for inpatient services. We looked at the file and Medicare rules. Procedure code 01402 (anesthesia for knee arthroplasty) was billed with POS code 22 for an outpatient hospital. The enrollee was under inpatient status for the date of service at issue and the services should be billed with POS code 21. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 2020.
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 testing is not covered.
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, a molecular genetic screening testing panel, 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 the laboratory services rendered on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse up to the $100 maximum for the periodontal maintenance (D4910) and the bitewing x-ray (D0274) provided on February 10, 2021.
You asked the Plan to reimburse up to the $100 maximum for the dental services. You say that your care is provided on a 4-month rotation. You say that your insurance offers a once-yearly cleaning and check up with a $100 reimbursement. You also say that you feel you are entitled to the $100 reimbursement. The Plan denied your request. The Plan says periodontal maintenance is not a covered service. The Plan says that x-rays are not 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse up to the $100 maximum for the periodontal maintenance (D4910) and the bitewing x-ray (D0274) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care services rendered on January 11, 2021.
You asked the Plan to waive the copayment for these services. You say that you made an appointment with your PCP but had to see another provider because it was an urgent care visit. The Plan denied your request. The Plan says the copayment was 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 $45 copayment for each covered office visit to other providers for urgently needed services.
Review of the file shows that you received urgent care services on January 11, 2021. You have been asked to pay a $45 copayment for these services. These services fall within the covered office visit to other providers for urgently needed 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 copayment for the urgent care services rendered on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for syncope. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical
and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically
necessary care can be provided in a different level of care. There is not a reasonable expectation that this
enrollee 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step-therapy exception criteria.
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 Durolane. Our reviewer says that the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found the documentation does not show that the use of the Plan's required drugs 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
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 you disagree with the denial. The Plan denied your
request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 medically necessary. Our physician reviewer found the records show that you were
admitted to the hospital on April 30, 2021 with a stroke. The therapy notes state that you are walking 160 feet
with assistance and are able to perform toilet transfers and tub/shower transfers with assistance. You do not
require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20900) provided on October 20, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 20900 is "Bone graft, any donor area; minor or small (eg, dowel or button)". We asked our coding 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 services. Our reviewer says that the use of CPT code 20900 is not supported by the records provided. Our coding reviewer found that per CPT code guidance, code 20900 excludes bone graft procedures on the spine (20930 - 20938), therefore it is inappropriate to bill this code for the services performed on October 20, 2020. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20900) provided on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse the enrollee for the pool handrail purchased on September 1, 2020.
You asked the Plan to reimburse the enrollee for the pool handrail. You say that the enrollee uses the pool for exercise and needs the handrail to get in. The Plan denied your request. The Plan says the enrollee purchased the equipment from a provider who is not eligible to participate in Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also say no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse the enrollee for the pool handrail purchased on September 1, 2020.