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

We decided that the Plan does not have to pay for pharmacogenomic testing (81479) and MTHFR genetic
testing (81291) provided on December 17, 2020.
You asked the Plan to pay for genetic tests. You say that the enrollee clearly met the criteria for this testing.
The Plan denied your request. The Plan says these tests do not meet the criteria for coverage.
The Plan follows Medicare rules. Medicare rules state that pharmacogenomics testing is only covered under
certain conditions. MTHFR genetic testing 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 pay for genetic tests. Our reviewer says that the
pharmacogenomic testing does not meet the Medicare criteria for coverage. Our physician reviewer found the
enrollee has an anxiety disorder. There was no specific clinical rationale for this laboratory study.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not
have to pay for pharmacogenomic testing (81479) and MTHFR genetic testing (81291) provided on December
17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on December 15, 2020, billed
with code 21014.

You asked the Plan to pay for the services as billed. You say that this should be paid as billed. The Plan denied
your request. The Plan says the records do not support the services described by code 21014.

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 21014 is excision, tumor, soft tissue of face and scalp,
subfascial (e.g., subgaleal, intramuscular); 2 cm or greater.

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 as billed. Our reviewer says that
the documentation does not support this code. Our coding reviewer found the operative report does not provide
enough documentation to confirm excision of tumor. There is no documentation to support type of lesions, as
no supporting documentation of pathology reports were submitted. Therefore, CPT 21014 cannot be
confirmed.

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 as billed have not been met. Therefore, we decided that the Plan
does not have to pay for the surgical services provided on December 15, 2020, billed with code 21014.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve an expandable controller. We decided that the Plan does not have
to pre-approve a power seat elevation system.

You asked the Plan to pre-approve an expandable controller. You say that the enrollee needs these items. The
Plan says that these items are not necessary.

We decided that the Plan has to pre-approve an expandable controller.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is
medically necessary for a function described in the LCD.

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 expandable controller. Our reviewer
says that the requirements for coverage of the requested expandable controller have been met. Our physician
reviewer found based on the medical records provided, there is documentation that the requested expandable
controller is medically necessary to operate 3 or more powered seating actuators through the drive control. The
enrollee has 2/5 upper extremity strength and is dependent for all activities of daily living including feeding,
grooming and hygiene.

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 expandable controller have been met. Therefore, we decided that the Plan
has to pre-approve an expandable controller.

We also decided that the Plan does not have to pre-approve a power seat elevation system.

The Plan follows Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because
it is not primarily medical in nature.

We looked at the file and Medicare rules. The requested item is excluded from Medicare coverage. Based on
this information, we decided that Medicare rules for coverage of a power seat elevation system have not been
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH admission is medically necessary. The enrollee would benefit from transfer to LTACH as he requires high nursing needs that are unable to be met in a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to LTACH

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 the enrollee is receiving acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.

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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a neurologist office visit to be provided by an out of network provider.
You asked the Plan to pre-approve a neurologist office visit with an out of network provider. You say that in the past you saw a different doctor who was not able to help you. The Plan denied your request. The Plan says you have been approved for an office visit with an in-network neurologist.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a neurologist office visit to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bronchodilation responsiveness diagnostic testing (94060) provided on January 6, 2021.
You asked the Plan to waive the copayment for diagnostic testing. You say that you paid your copayment at the time of your visit. You also say that you have never been charged a copayment for this test. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $95 copayment for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $95 copayment for diagnostic testing with a specialist. The EOC confirms that $95 is the required copayment for this service. The record shows that the Medicare Allowed Amount for the service at issue is $53.71. This is lower than your required copayment responsibility of $95. Diagnostic testing falls 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 bronchodilation responsiveness diagnostic testing (94060) provided on January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chiropractic office visit (Current Procedural Terminology (CPT) code 99203-25), cervical/spine x-ray (CPT code 72040, spine/thoracic x-rays (CPT code 72070) and spine/lumbosacral x-ray (CPT code 72100)provided on January 11, 2021, by an in-network provider.

You asked the Plan to waive the copayment for the services. You say that you were billed for three separate x-rays that were done in one setting. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC 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). 

Review of the file shows that the chiropractic office visit (CPT code 99203-25), cervical/spine x-ray (CPT code 72040, spine/thoracic x-rays (CPT code 72070) and spine/lumbosacral x-ray (CPT code 72100) on January 11, 2021, by an in-network chiropractor. The Plan states they determined to reverse their decision and pay less then a $20 copay for the non-Medicare covered routine visit. The Plan also agrees to pay less than a $35 copay for one x-ray by a chiropractor. Your 2021 EOC states enrollees must pay a $20 copayment for each in-network Medicare-covered visit, a $20 copayment for each in-network non-Medicare covered routine visit, up to twelve (12) visits each year, and a $35 copayment for in-network non-Medicare covered x-ray services performed once per year by a chiropractor (you would pay this in addition to your visit). 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 chiropractic office visit (Current Procedural Terminology (CPT) code 99203-25), cervical/spine x-ray (CPT code 72040, spine/thoracic x-rays (CPT code 72070) and spine/lumbosacral x-ray (CPT code 72100)provided on January 11, 2021, by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated socket insert.
You asked the Plan to pre-approve the requested item. The Plan denied your request. The Plan says the code is only for initial use with a prosthesis.
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 L5861 is Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code l5673 or l5679).
We looked at the file and Medicare rules. We find that the requested item, L5681, is not being requested for initial use. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated socket insert.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fender and ultra-low rehab seat for a power wheelchair.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the fender does not serve a medical purpose, and the seat cushion does not have Medicare approval.
The Plan must follow Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications. We looked at the file and Medicare rules. The fender does not serve a purpose that is primarily medical in nature. A prefabricated seat cushion which has not received a written coding verification is not reasonable and necessary.
Based on this information, we decided that Medicare rules for coverage of the requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve a fender and ultra-low rehab seat for a power wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services provided from November 17, 2020, through December 1, 2020.
You asked the Plan to waive the copayment for the physical therapy services. You say that you believe you do not owe this bill and do not intend to pay it. The Plan denied your request. The Plan says the claims were processed accordingly with your 2020 EOC 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). Review of the file show that you received physical therapy services for five (5) dates of service from November 17, 2020, through December 1, 2020. You were asked to pay a $25 copayment per date of service
for physical therapy. Your total cost share responsibility is $125 ($25 x 5 dates of service = $125). Your 2020 EOC states enrollees must pay a $25 copayment for each Medicare-covered physical therapy and speech-language therapy visit. 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 physical therapy services provided from November 17, 2020, through December 1, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. 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 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 medically necessary. Our physician reviewer found you were admitted to the hospital on June 2, 2021 after being involved in a motor vehicle accident and underwent surgery on June 3, 2021. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cataract surgery to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the cataract surgery. You say that you the enrollee's daughter and understand the enrollee's medical conditions. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the cataract surgery to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220), and the crown (D2740) provided on March 1, 2021.
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services performed out of network are 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 and the services are listed as covered, dental services performed out of network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220), and the crown (D2740) provided on March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0651) provided on February 24, 2021.

You asked the Plan to pay for a lumbar-sacral orthosis. 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. 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 lumbar-sacral orthosis (L0651) provided on February 24, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. 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.

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 Retacrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review indicates that the enrollee does not meet criteria for coverage. There is no documentation of a transferrin level of at least 20% and a ferritin of at least 100 ng/ml, within the last 4 months. The review indicates that the requested Retacrit is not medically necessary or 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the daratumumab 10mg injection (J9145)
provided on January 27, 2021 and February 27, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has 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). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for chemotherapy drugs provided at a PCP's office, a specialist's office, or an outpatient hospital
setting.
You have been asked to pay $2,849.20 for the chemotherapy injections provided. This includes the Plan
allowed amount of $8,797.81 x 20% coinsurance=$1,759.56 for the first injection. Additionally, this includes
the Plan allowed amount of $8,517.62 x 20% coinsurance=$1,703.52 for the second injection; which has been
reduced to a coinsurance of $1,089.64 as you have met the out of pocket maximum allowable for this calendar
year. 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 the daratumumab 10mg injection (J9145) provided on
January 27, 2021 and February 27, 2021.