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

We decided that the Plan does not have to pay forthe chiropractic services (99211, 97014, 97010) you received on November 12, 2019.You asked the Plan to pay forthe chiropractic services. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (99211, 97014, 97010) youreceived on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).You asked the Plan to pre-approvea pneumatic compression device. You say that based on the enrollee's negative response to treatment, the physician did not recommend continued use of a basic pump.The Plan denied your request. The Plan says the denial of authorization for these items is correct, because the enrollee did not fail a 4-week trial of daily, regular, multiple-hour home usage of a basic lymphedema pump.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approvea pneumatic compression device (E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveJanumet for the enrollee.You asked the Plan to pre-approveJanumet. You say that the enrollee has tried other medications with adverse outcomes.The Plan denied your request. The Plan says Janumet to be administered at home is not covered under the Part B 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-approveJanumet for the enrollee.Benefits for Janumetmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT) services.You asked the Plan to pre-approvethe CT scan. You say that the requested CT scan is medically necessary to make sure the medications she is taking are helping with her condition. The appellant says that in order to move forward and get the care she needs, the requested CT scan is needed.The Plan denied your request. The Plan says the records do not show the results of a recent exam, what led to the test being requested, or the results of lab studies.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve the CT scan. Our reviewer says that the requested CT scan is not medically reasonable and necessary. Our physician reviewer found a CT scan of the abdomen was requested for a diagnosis of benign neoplasm of unspecified adrenal gland. The only supporting documentation available for review was laboratory data from March 9, 2020, including a urinalysis, urine culture showing an E coli infection and a complete blood count. No history of the adrenal gland neoplasm, results of previous imaging or results of examination were available for review.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received on April 5, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the claim needs to be processed by the primary insurer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has identified the primary insurer for the date of service in question. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe services you received on April 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approveF2 and F5 genetic testing for the enrollee. You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that F2 and F5 genetic testing is non-covered.The services at issue are F2 and F5genetic testing. This testing is not covered by Medicare for any indication.Therefore, we decided that the Plan does not have to pre-approveF2 and F5 genetic testing for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea dental implant.You asked the Plan to pre-approvea dental implant. The Plan denied your request. The Plan says the requested service is not a covered benefit.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.Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvea dental implant.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain radiating into the lower extremities. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of the Vertiflex spacer for this enrollee's medical condition. The services are considered experimental/investigational in nature and are not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on August 4, 2019.You asked the Plan to pay for ambulance services. You say that the claim should be paid.The Plan denied your request. The Plan says during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness.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 for ambulance services provided to the enrollee on August 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an aflibercept injection provided by a participating provider on January 10, 2020.
You asked the Plan to waive the coinsurance for an injection. You say that you cannot afford this coinsurance. 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 allowed amount is $1,960.76. The total amount you are being asked to pay is $392.15 ($1,960.76 x 20% = $392.15). 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 aflibercept injection provided by a participating provider on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dual-energy x-ray provided on December 26, 2019 by an out of network (OON) provider.You asked the Plan to pay for dual-energy x-ray. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.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 dual-energy x-ray provided on December 26, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for date of service June 25, 2019.You asked the Plan to pay for date of service June 25, 2019. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.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 is denying payment for date of service June 25, 2019 as a duplicate for CPT code 92014.The documentation shows that claim number appears to be a corrected claim. Claim number provided by the Plan does not show that CPT code 92014 was paid at the Medicare allowable amount by the Plan. Furthermore, the Plan is denying payment for HCPCS code J7312 as not a valid National Drug Code number. However, per the AMA, which Medicare follows, HCPCS code J7312 is a valid code for payment.We find that the Plan has not substantiated their reasoning for denial of payment as the Plan did not provide a claim showing that CPT code 92014 was previously paid at the Medicare allowable rate by the Plan. ThePlan also has not provided any documentation that shows that HCPCS code J7312 is not payable by Medicare as HCPCS code J7312 is a valid AMA code.Therefore, we decided that the Plan has to pay forclaim number  for date of service June 25, 2019.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 12, 2019.You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to be in the operating room during the length of the procedure.The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved.
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 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 medical services provided to the enrollee by an out-of-network provider on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forCBD oil provided on December 12, 2019.You asked the Plan to reimburse you for the CBD oil. You say that this is an over-the-counter medication that helps with your medicalcondition.The Plan denied your request. The Plan says CBD oil is not on the Flex Benefit eligible items list.The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay for nutritional supplements. The Plan contract offers a Flex benefit that provides a supplemental benefit for the purchase of non-Medicare healthcare items.We looked at the file the Medicare rules and the Plan's rules.  The file shows that CBD oil is not on the Flex benefit eligible items list. Therefore, we decided that the Plan does not have to reimburse you for the CBD oil providedon December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 4, 2019.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).You asked the Plan to pre-approve Keytruda. You say that this is the appropriate next line of therapy.The Plan denied your request. The Plan says Keytruda is not supported for the enrollee's condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Medicare coverage criteria for Keytruda have not been met in this case. Our physician reviewer found the drug is not FDA approved for maintenance therapy in the enrollee's situation, and it is not supported for maintenance therapy in this clinical setting in any of the CMS approved compendia.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 (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesix additional chiropractic visits.You asked the Plan to pre-approvethese services. You say that the enrollee is on a fixed income which causes a delay in his treatment. Additionally, you say that if he could afford to come more often, there would be more progress with his treatment.The Plan denied your request. The Plan says that when further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature. The treatment is then considered maintenance therapy, which is not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve these services. Our reviewer says that the enrollee does not meet criteria for coverage of additional chiropractic services. Our physician reviewer found the records indicate that the diagnoses remain the same and treatment remains, essentially, the same throughout the careprovided on a monthly basis. The treatment is to prevent deterioration of a chronic condition, there is no evidence that any clinical improvement has occurred or that any clinical improvement will occur with any further treatment. The chiropractic treatment is supportive, rather than corrective in nature, which is considered maintenance therapy, and is not supported or allowed per Medicare guidelines.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvesix additional chiropractic visits.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered to enrollee on October 20, 2019.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 submitted records do not support the billing of code 99285.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 99285 is Level 5 emergency department visit for evaluation and management of patient withproblem immediately threatening life, including comprehensive history and physical examination, and medical decision-making of high complexity.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 these services. Our reviewer says that the submitted records do not support the billing of code 99285. Our physician reviewer found the billing of CPT 99285 requires a comprehensive history, comprehensive examination and high-complexity medical decision making. The enrollee's complaint was of a chronic cough without chest pain or shortness of breath. The evaluation she received was standard for such a complaint. No life/limb threatening issueswere identified. The enrollee was discharged to home with a cough medication. Such an interaction does not convey high-complexity medical decision making. The billing of CPT 99285 is not supported.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe emergency room (ER) services rendered to enrollee on October 20, 2019.