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

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve the Prolia. You say that Prolia is medically necessary.The Plan denied your request. The Plan says a trial of Zoledronic Acid 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 the Prolia. Our reviewer says that rules for coverage were not met. Our physician reviewer found there was no trial of the plan preferred drug or any documentation showing that it would be unsafe or ineffective.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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for bronchoscopy services (31626, 31627, 31628 and 31653) provided on September 17, 2019.
You asked the Plan to pay for the bronchoscopy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted note indicates this procedure was rendered on a different date of service.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We find that CPT code 31626, 31627, 31628 and 31653 is not supported in the record. Specifically, the documentation does not support that this procedure was rendered on the billed date of service. The record indicates that this procedure was rendered on September 16, 2019. Based on this information, we decided that Medicare rules for coverage of the bronchoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for bronchoscopy services (31626, 31627, 31628 and 31653) provided on September 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for inpatient hospital care (99222), outpatient surgery (93458), and cardiac rehabilitation services (93015) provided October 2, 2019 to November 8, 2019.You asked the Plan to waive the cost-sharing for the inpatient care, outpatient surgery and cardiac rehabilitation services. You say that the deductible and copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was 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 $1,000 deductible, a $40 copayment for Cardiac Rehabilitation and a $350 copayment for outpatient surgery. You have been asked to pay a $102.50 towards the deductible, a $40 copayment for Cardiac Rehabilitation and a $350 copayment for outpatient surgery. 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-sharing for inpatient hospital care (99222), outpatient surgery (93458), and cardiac rehabilitation services (93015) provided October 2, 2019 to November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on April 29, 2019.
You asked the Plan to pay for the genetic 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The genetic testing at issue in this appeal 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 genetic testing provided on April 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on January 16,
2020.
You asked the Plan to waive the copayment for laboratory services. You say that you shouldn't have a separate
copayment for services done on the same date. 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 $10 for
Medicare-covered laboratory tests.
You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests
are considered a separate service. 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 laboratory services
provided on January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for Inpatient Hospital services provided
October 10, 2019 to October 16, 2019.
You asked the Plan to waive the cost-sharing for the inpatient hospital services. You say that the copayment
should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $675
copayment after the $1,000 deductible is met for Inpatient Care.
You have been asked to pay $1,000 towards the deductible and a $675 copayment is for the inpatient hospital
services. 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-sharing for Inpatient Hospital services provided October
10, 2019 to October 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) rendered by the out of network (OON) provider on January 7, 2020.
You asked the Plan to issue reimbursement for the hearing aids. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) rendered by the out of network (OON) provider on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on January 25, 2020, for a non-participating provider.You asked the Plan to pay for the services. You say that the claim should be paid.The Plan denied your request. The Plan says payment was already made for same/similar procedure within the set time frame.The Plan must follow Medicare rules. We looked at the file and Medicare rules.Based on this information, we decided that Medicare rules for coverage of the services have not been met. In accordance with CMS Claims Processing Manual, Hospital Discharge Day Management Service Hospital Discharge Day Management Services, CPT code 99238or 99239 is a face-to-face evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay. Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range 99231 -99233) for a final visit. Based on the information obtained upon admission the attending physician was not the same provider that is appealing and the attending physician was paid for the discharge for this member.Therefore, we decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes (CPT Code 99239) provided to the enrollee on January 25, 2020, for a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Multaq.You asked the Plan to pre-approve Multaq. The Plan denied your request. The Plan says this is not a covered benefit.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 Multaq.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home ventilator non-invasive interface (E0466). You asked the Plan to pre-approve home ventilator non-invasive interface. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the non-invasive ventilator is not medically necessary at this time.The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator non-invasive interface. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the coverage criteria for a home ventilator are not met. This enrollee has severe COPD with chronic hypercapnic respiratory failure. He has been prescribed BiPAP, but usage data do not meet the minimum criteria of at least 4 hrs/day for at least 70% of days. There is no evidence of failure of BiPAP. Therefore, a home ventilator is 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 home ventilator non-invasive interface have not been met.Therefore, we decided that the Plan does not have to pre-approve home ventilator non-invasive interface (E0466).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 9, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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, the laboratory service, 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 provided on December 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forelectrocardiography services (CPT 93010) provided to the enrollee on December 20, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says this was denied as an emergency room visit (CPT 99285) was billed on the same date of service by the same provider.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 93010 is "ECG with at least 12 leads; interpretation and report only."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 services at issue in were not supported by the submitted medical records. Our coding reviewer found no documentation of a written report was submitted, and would be considered part of the E/M code.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 forelectrocardiography services (CPT 93010) provided to the enrollee on December 20, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for surgical services provided on June 25, 2018 through July 25, 2018.You asked the Plan to pay for the surgical services. You say that you would like reconsideration because these services were billed correctly.The Plan denied your request. The Plan says that payment has been retracted because of incorrect billing.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has failed to forward any justification as to why this service was billed incorrectly. Additionally, medical records were requested from the Plan and not received.Therefore, we decided that the Plan has to pay for surgical services provided on June 25, 2018 through July 25, 2018.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 genetic testing provided on October 23, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-network provider ithout 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 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 genetic testing provided on October 23, 2019
by an out of network (OON) provider.
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 are not at baseline. You say that you need
intense therapy to reach your goal and to be able to go home. The Plan denied your request. The Plan says IRF
care 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 above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that LTACH services are medically necessary for the enrollee.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, the enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Medicare coverage criteria for transfer to an LTACH 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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveimage guided radiation therapy (IGRT).You asked the Plan to pre-approveIGRT. 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 medically necessary.The Plan follows Medicare rules. Medicare rules say that IGRT is only covered for certain indications.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 IGRT. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has sternal metastasis. For radiation in the palliative setting, IGRT could be considered medically necessary when it is necessary to escalate the dose (i.e. oligometastases), particularly when using very high dose per fraction, or when critical normal tissues abutting the target necessitate dailyimage guidance to allow minimal planning margins to spare the normal tissue. In this case, the intent is clearly palliative, and it is not clear what benefit IGRT would afford. No plausible rationale for the need of IGRT is provided. The work sheet statesthat "tight margins necessary to decrease heart/lung dose" though this would generally only apply for curative intent cases, or when a dosimetric rationale is provided. Though IGRT is simply being used as routine practice, as there does not seem to be anyexceptional circumstances with this enrollee necessitating the need for IGRT. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met.Therefore, we decided that the Plan does not have to pre-approveimage guided radiation therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 test provided to the enrollee on February 3,
2020.
You asked the Plan to pay for the test. You say that the medical evidence supporting this test spans five peerreviewed
publications, including a clinical validation study published in Plos One 2015. The Plan denied your
request. The Plan says there are participating providers associated with participating facilities that can perform
or supply this service.
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 Guardant360 test provided to the enrollee on
February 3, 2020.