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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
February 23, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services at issue in this appeal. 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 the services provided by an out-of-network provider on February
23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0032U, 81225, 81226, 81227, 81230, 81231,
81232, 81240, 81241, 81283, 81328, 81335, 81346, 81355, 81408, 81479) provided November 12, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory
tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The plan documentation shows no history of a relationship between
the ordering physician and the enrollee in the case. There is no history of an office visit claim to indicate that
the ordering physician is treating the enrollee. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (0032U, 81225, 81226, 81227, 81230,
81231, 81232, 81240, 81241, 81283, 81328, 81335, 81346, 81355, 81408, 81479) provided November 12,
2020.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy services (90837) provided on December 29, 2020.
You asked the Plan to pay for psychotherapy services. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says that rules for payment have not been met.
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. Specifically, the Plan has failed to substantiate what necessary criteria the provider has not met. We found that the provider is licensed in the state where the services were performed and is certified by Medicare. There is no compelling evidence why the provider should not receive payment for the services rendered. Therefore, we decided that the Plan has to pay for the psychotherapy services (90837) provided on December 29, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on June 29, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied 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. Per LCD L36358, the requested test is not covered. 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 for the cardiovascular risk assessment panel provided on June 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on January 29, 2021.
You asked the Plan to waive the copayment for the endoscopy. You say that this amount is too high, and you cannot afford to pay. 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 $0 or $275 copayment for each Medicare-covered outpatient hospital facility visit. A $0 copayment for any surgical procedures (i.e., polyp removal) during a colorectal screening. A $275 copayment for all other outpatient services not provided in an ambulatory surgical center.
You have been asked to pay a $275 for the endoscopy. The endoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 endoscopy provided on January 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the enrollee's family feels that they have skilled needs with the enrollee's new peg tube and wound care. The Plan denied your request. The Plan says the stay is not medically necessary.

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 there are identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) spinal canal and contents (72141) magnetic resonance imaging (MRI) any joint of upper extremity (73221) provided August 29, 2020, to November 20, 2020.
You asked the Plan to waive the copayment for the diagnostic services. You say that you did not know that
your Medicaid covered your premiums and copays during these dates of service, and you had paid each of
them. You paid the $5 copay for your office visits and they should be waived due to COVID. The Plan denied
your request. The Plan says the claims have been reprocessed and the correct cost shares have 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 $150
copayment for Medicare covered diagnostic procedures and tests for Outpatient diagnostic tests and therapeutic
services and supplies.
You have been asked to pay $270 ($135 x 2) for the diagnostic services. The applied copayment amount of
$135 is less than the $150 amount, therefore you are responsible for the lesser amount. The diagnostic services
fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 magnetic resonance imaging (MRI) spinal canal and contents
(72141) magnetic resonance imaging (MRI) any joint of upper extremity (73221) provided August 29, 2020, to
November 20, 2020.
Your complaint about your premiums is not a valid appeal for medical coverage. This part of your complaint is
a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these
types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on May 19, 2020.

You asked the Plan to pay for the out-of-network ophthalmology services. You say that the injection was the recommended dosage period for the drug so the Plan should send the claim for reprocessing. The Plan denied your request. The Plan says the enrollee had used the entire coverage limit prior to this service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. The enrollee's contract with the Plan says that there is a point-of-service coverage limit of $3000 per calendar year.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a point-of-service coverage limit of $3000 per calendar year for using out-of-network providers. This benefit limit had been reached at the time the out-of-network ophthalmology services were received on May 19, 2020. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on May 19, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on March 9, 2021.

You asked the Plan to pay for an x-ray. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.

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, we have confirmed that code 71045 has a bundled relationship with code 32555 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1833) and suspension sleeve (L2397)
provided on March 29, 2021.

You asked the Plan to pay for a knee brace and suspension sleeve. You say that the requested item is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for durable medical equipment
have not been met.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the
document submitted as proof of delivery cannot be matched to the supplies provided. The record shows that the
Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that
the Plan does not have to pay for a knee brace (L1833) and suspension sleeve (L2397) provided on March 29,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 22, 2021.
You asked the Plan to pay for the laboratory testing. You say that this should be covered based on the LCD. The Plan denied your request. The Plan says the Medicare rules have not been 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 pay for the laboratory testing. Our physician reviewer found the review has determined that GeneSight Psychotropic is not covered by Medicare. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage.
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 laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic test (CPT code 81479) provided to the enrollee on January 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) provided
on January 14, 2021.
You asked the Plan to pay for an intermittent limb compression device. You say that the requested item is a
necessity for the enrollee's care. The Plan denied your request. The Plan says pneumatic compression devices
are not covered by Medicare for prevention of thrombotic events such as deep venous thrombosis (DVT) or
pulmonary embolisms (PE).
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression
device (E0675) provided on January 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Pembrolizumab is FDA approved for the treatment of mismatch repair deficient (dMMR) in patients who have disease progression following prior systemic therapy and are not candidates for curative surgery or radiation. This enrollee has not had any prior therapy and would not meet criteria for treatment. The service is not reasonable or 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injections.
You asked the Plan to pre-approve sacroiliac joint injections. 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 follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary for the diagnosis and treatment of chronic pain when specific criteria 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 sacroiliac joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found there are no physical findings or imaging to support the diagnosis of Sacroilitis. The request is therefore, deemed not medically reasonable or 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 sacroiliac joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the replacement of a gastrostomy tube 
(43762) and the emergency room visit (99284) provided on February 16, 2021. 
 
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 
the services provided. 
 
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 enrollee's contract with the Plan clearly says that enrollees 
must pay a $225 copayment for each outpatient surgery and/or services at an ambulatory surgical center or 
outpatient hospital facility. Additionally, enrollees must pay a $90 copayment for each emergency room visit. The enrollee has been asked to pay a $225 copayment ($200.91 + $24.09) for the outpatient surgery and 
emergency room visit provided. This amount is less than the applicable copayments for these services. This 
means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost 
sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided 
that the Plan does not have to waive the copayments for the replacement of a gastrostomy tube (43762) and the 
emergency room visit (99284) provided on February 16, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca (Q5111). 
 
You asked the Plan to pre-approve Udenyca. You say that Udenyca is medically necessary The Plan denied 
your request. The Plan says that coverage criteria has not been met. The records do not show the enrollee has a 
greater than 10% risk of febrile neutropenia. 
 
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 Udenyca. Our reviewer says that 
Udenyca is medically necessary. Our physician reviewer found given the patient's age and prior chemotherapy, 
there is a greater than 20% risk of febrile neutropenia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Udenyca have been met. Therefore, we decided that the Plan has to pre-approve 
Udenyca (Q5111).  
 
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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve an additional 400 units of Botox.
You asked the Plan to pre-approve an additional 400 units of Botox. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that botulinum toxin can be used to reduce spasticity or excessive muscular contractions, to relieve pain, to assist with posture and walking, to improve range of motion, to enhance the effectiveness of physical therapy, and to reduce severe spasm to allow better perineal hygiene. 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 additional 400 units of Botox. Our reviewer says that the medication is medically necessary. Our physician reviewer found the review has determined that the enrollee meets the coverage criteria detailed in the LCD. The requested Botox is medically necessary and reasonable. 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 additional 400 units of Botox have been met. Therefore, we decided that the Plan has to pre-approve an additional 400 units of Botox.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT code K0606-RR, KF, KH, KX) provided to the enrollee on February 12, 2021.
You asked the Plan to pay for the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the diagnosis is inconsistent with the procedure. This should be billed with the appropriate code for this service.
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 DME have not been met. Automatic External Defibrillators, the billed diagnosis I47.1 (Supraventricular tachycardia) is not on the list of approved diagnosis for K0606. Therefore, we decided that the Plan does not have to pay for automatic external defibrillator, with integrated electrocardiogram analysis, garment type (CPT code K0606-RR, KF, KH, KX) provided to the enrollee on February 12, 2021.