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

We decided that the Plan does not have to pay for low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (Q9967) provided October 8, 2019.
You asked the Plan to pay for code Q9967. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not supported by the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 code Q9967. Our reviewer says that code Q9967 is not supported by the medical records. Our coder reviewer found the medical records submitted do not include documentation of Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code Q9967 have not been met. Therefore, we decided that the Plan does not have to pay for low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (Q9967) provided October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda injections (J9271, J9267, and J9045).You asked the Plan to pre-approve Keytruda injections. You say that the requested 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 injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found for those with metastatic or recurrent head and neck cancer without prior exposure to systemic therapy, the combination of pembrolizumab plus chemotherapy improves overall survival beyond that seen with cetuximab plus chemotherapy. However, the typical regimen is pembrolizumab plus carboplatin and fluorouracil. Therefore, although pembroliizumab is safe and reasonable and necessary the combination with paclitaxel is not a category 1 recommendation from the NCCN Guidelines.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 injections have not been met.Therefore, we decided that the Plan does not have to pre-approve Keytruda injections (J9271, J9267, and J9045)
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception 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 Procrit. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Retacrit (Epoetin alfa-epbx) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit (J0885).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.You asked the Plan to pre-approve additional transportation. You say that you are confined to a wheelchair, and have no other way of getting to your appointments.The Plan denied your request. The Plan says your benefit only allows 24 trips for this service.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way trips per year. We looked at your request, the records in the case file, and the rules. Once you have used 24 one-way trips, you will have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches for the enrollee.
You asked the Plan to pre-approve Fentanyl patches. The Plan denied your request. The Plan says Fentanyl 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-approve Fentanyl patches for the enrollee.
Benefits for Fentanyl patches may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306).
You asked the Plan to pre-approve a TTE. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a TTE. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records you have no cardiac symptoms, no cardiac exam abnormalities, no documented electrocardiographic abnormalities and scheduled non-high risk laryngeal surgery. In this circumstance the records do not support the medical necessity for a preoperative echocardiogram. Echocardiography is not considered and accepted screening test preoperatively according to published guidelines. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a TTE have not been met. Therefore, we decided that the Plan does not have to pre-approve a transthoracic echocardiography (TTE) (93306).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided by Perinton Ambulance on July 24, 2019.You asked the Plan to pay for the ambulance services, claim #E14065956100. You say that you should only have to pay the copayment.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 24, 2019. The ambulance benefit is a transportation benefit.When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services provided by Perinton Ambulance on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia for open procedures involving hip joint (01210-QZ) provided November 20, 2019.You asked the Plan to pay foranesthesia for open procedures involving hip joint. You say that these services were medically necessary.The Plan denied your request. The Plan says the billed services are not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We askedour 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 anesthesia for open procedures involving hip joint. Our reviewer says that anesthesia foropen procedures involving hip joint (01210-QZ) is not supported. Our physician reviewer found the medical records include documentation that indicates the anesthesia service 01210 was performed with medical direction/medical supervision, therefore, the use of a QZ modifier indicating services delivered without medical direction by a physician is inappropriate. The modifier choices that are appropriate when there is medical direction/medical supervision are QY, QX, and AD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia for open procedures involving hip joint have not been met. Therefore, we decided that the Plan does not have to pay foranesthesia foropen procedures involving hip joint (01210-QZ) provided November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy services (96413, 96417, 96415, 96367, 96368, 96377) provided August 1, 2019.
You asked the Plan to pay for chemotherapy services. You say that these services were medically necessary. The Plan denied your request. The Plan says the medical records do not support the billed codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 chemotherapy services. Our reviewer says that the billed codes are not supported by the medical records. Our physician reviewer found the medical documentation submitted does not include documentation of the billed codes. In addition, code 96377 has a bundled relationship with code 96413 which was billed on the same date of service. A modifier is allowed to unbundle the service as long as the medical records can validate the appropriate usage of the appended modifier. In this case, there is an inappropriate use of the 59 modifier. The medical records provided do not validate that procedure 96377 was performed as a distinct or independent service from 96413 that was performed on the same day. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chemotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy services (96413, 96417, 96415, 96367, 96368, 96377) provided August 1, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the infrared therapy provided from April 8, 2019 to May 20, 2019.You asked the Plan to provide reimbursement forthe infrared therapy. You say that you feel that you should be reimbursed in fullfor what you paid.The Plan denied your request. The Plan says these visits were approved at the Medicare allowed fee of $6.51 per visit for which you were reimbursed 80%. This is in accordance with your contract. Further reimbursement is not allowed.The Plan must follow Medicare rules. Medicare rules say that plans must pay the Medicare-allowed amount for services provided out of network and a Medicare provider must accept this as payment in full. Your contract also says that you must pay 20% coinsurance for out of network therapy. In this case, the Plan has reimbursed the allowed amount for each service less the 20% coinsurance. No additional payment can be required of the Plan for these services.Therefore, we decided that the Plan does not have to provide reimbursement forthe infrared therapy provided from April 8, 2019 to May 20, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from April 24, 2019 to May 23, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in aSNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on 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 the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from April 24, 2019 to May 23, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the brace on June 28, 2019.
You asked the Plan to waive the coinsurance for the brace. You say that you were not told the durable medical equipment provider was out-of-network. The Plan denied your request. The Plan says the claim has been reprocessed to the in-network benefit
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 20% coinsurance for each Medicare-covered item. You have been asked to pay $133.65 which is 20% of the allowed amount for the brace. The allowed amount is $668.26. ($668.26 x 20% = $133.65). The brace falls within the "Durable medical equipment (DME) and related 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 coinsurance for the brace provided on June 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe frames (V2020) bifocal lenses (V2200) non-covered item (A9270) and sales tax(S9999) provided October 25, 2019.You asked the Plan to pay forthe vision services. You say that it says that you will pay up to $250. It does not say that upgrades are excluded.The Plan denied your request. The Plan says the non-covered item and sales tax are not covered benefits. Reimbursement was issued on November 18, 2019 for $89.93 and December 26 for $36.14 totaling $126.07.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for Medicare covered eye wear provided by out of network providers. for Vision care. You have been asked to pay $162.28. The plan contract says you pay 50% coinsurance for Medicare covered eye wear provided by out of network providers. The vision services fall within the Vision care 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 pay fordeluxe frames (V2020) bifocal lenses (V2200) non-covered item (A9270) and sales tax (S9999) provided October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthesis items to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. You say that the prosthesis from an in-network provider has resulted in large open wounds. The Plan denied your request. The Plan says there are providers within the enrollee's plan for the needed services.
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 out-of-network services. Therefore, we decided that the Plan does not have to pre-approve the prosthesis items to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit or the laboratory test provided on September 30, 2019.You asked the Plan to waive the copayment for the office visit and the laboratory test. You say that the lab services were a part of your wellness visit and you should not be responsible for the copayment. You say you were told you would not have to pay an office visit copayment if you asked the doctor about your back pain. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 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 $15 copayment for each Medicare covered PCP visit and a $20 copayment for each Medicare covered diagnostic procedure, test and/or lab service. You have been asked to pay a$15 copayment for the office visit and a $20 copayment for the laboratory test. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies"benefit category. The medical record shows you were treated for hypertension, hyperlipidemia, and pain in thoracic spine in addition to the annual wellness visit. The record also shows that the basic metabolic panel laboratory test is not considered a preventive lab.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 office visit or the laboratory test provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 95861) provided to the enrollee on October 23, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed service it not supported.
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 95861 is "Needle electromyography; 2 extremities with or without related paraspinal areas". 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 services. Our reviewer says that the use of CPT code 95861 is supported by the records provided. Our physician reviewer found that the documentation shows spontaneous EMG monitoring of the enrollee's lower extremities. 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 services have been met. Therefore, we decided that the Plan has to pay for the services (CPT 95861) provided to the enrollee on October 23, 2018.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe home health physical therapy services provided from October 2, 2019 to October 30. 2019.You asked the Planto pay forthe home health services. You say that you feel that this is billed correctly and should be paid.The Plandenied your request. The Plansaysthe claim does not include a Q-code that describes where the services were provided which is required.The Plan must follow Medicare rules. Medicare rules say that home health claims must include a line time with a Q-code reported to describe the location of the patient when services are rendered. The claim submitted does not include the required Q-code.Therefore, we decided that the Plandoes not haveto pay forthe home health physical therapy services provided from October 2, 2019 to October 30. 2019.