Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. 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 Ilumya. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Enbrel, Skyrizi, Cosentyx or Otezla before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on November 4, 2020.

You asked the Plan to pay for the eyeglasses. The Plan denied your request. The Plan says the claim denied correctly as the eyewear benefit was used on January 15, 2019 and would not be eligible for a $250 eyewear benefit allowance until January 15, 2021.

Medicare generally does not cover routine eyewear services. However, the Plan offers an eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services every 2 years.

We looked at the file and the Plan's rules. The file shows that the eyewear benefit was provided on
January 15, 2019. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on November 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Thallium tl-201 thallous chloride coded A9505 provided on July 6, 2020.
You asked the Plan to pay for the Thallium tl-201 thallous chloride. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 A9505 is Thallium tl-201 thallous chloride, diagnostic, per millicurie. We find that CPT code A9505 is not supported in the medical record. Specifically, the documentation submitted did not support that thallium Tl-201 thallous chloride, diagnostic, per mCi was administered on the billed date of service; therefore, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the Thallium tl-201 thallous chloride have not been met. Therefore, we decided that the Plan does not have to pay for the Thallium tl-201 thallous chloride coded A9505 provided on July 6, 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 the enrollee's clinical needs can be safely accommodated at the LTACH. The Plan denied your request. The Plan says the enrollee does not have multiple complex medical needs.
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 physician reviewer found that the enrollee presented to the hospital with worsening cough and fever. His hospital course was complicated due to desaturation when removed from high flow oxygen. The enrollee is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that he requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Favorable

We decided that the Plan has to pay for the electrocardiogram provided on December 1, 2020.

You asked the Plan to pay for the electrocardiogram. You say this service was for 24-hour observation and that prior authorization was not needed for observation. The Plan denied your request. The Plan says that no prior authorization was obtained.

The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. 

We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. The medical record shows that the electrocardiogram was provided as part of the course of the enrollee's emergency care. Therefore, we decided that the Plan has to pay for the electrocardiogram provided on December 1, 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional personal care services provided from April 21, 2020, to August 3, 2020.
You asked the Plan to pay for the personal care services. You say that the Plan was unable to provide a provider that would perform this service. The Plan denied your request. The Plan says these services were not processed for payment due to the maximum payment for 31 days already paid.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the personal care services have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. The Plan has approved 31 days of personal care services for coverage. Therefore, we decided that the Plan does not have to pay for the additional personal care services provided from April 21, 2020, to August 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services coded S9122 and G0156 provided from August 10, 2020 to August 28, 2020.
You asked the Plan to pay for the home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 find that CPT codes S9122 and G0156 are not supported in the medical record. Specifically, the documentation submitted did not include documentation of the time spent on these services; therefore, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services coded S9122 and G0156 provided from August 10, 2020 to August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on June 12, 2020.
You asked the Plan to pay for the office visit. You say that the claim has been submitted to both parties and are anticipating a payment resolution. The Plan denied your request. The Plan says prior authorization was not obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided by an out-of-network provider on June 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 15, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare
does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to
pay for the laboratory services provided on September 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral feeding supplies (B4035, B4150, B9002) provided on September 1, 2020, through September 30, 2020.
You asked the Plan to pay for the enteral feeding supplies. You say that you would like reconsideration because this claim is not for Skilled Nursing Facility services. The Plan denied your request. The Plan says Medicare guidelines any durable medical equipment furnished to inpatients in a covered Part A stay is included in the Skilled Nursing Facility Prospective Payment System rate.
The Plan must follow Medicare rules. Medicare rules say that POS code 31 should be used with services for patients in a Part A-covered SNF stay and POS code 32 should be used with services for beneficiaries in a noncovered stay. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the enteral feeding supplies have not been met. Specifically, the record indicates that the member was not in a Part A covered stay on the billed date of service. There is a more appropriate POS code for the services billed. Therefore, we decided that the Plan does not have to pay for the enteral feeding supplies (B4035, B4150, B9002) provided on September 1, 2020, through September 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on September 14, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on September 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 4, 2019 and
July 5, 2019.
You asked the Plan to pay for the laboratory services. You say that you were waiting for the original payment to be recouped, which was not done timely. The Plan denied your request. The Plan says the claim was filed past the allowed 12-month time frame.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the laboratory services was not filed until November 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for laboratory services provided on July 4, 2019 and July 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on June 17, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the submitted medical records do not include a signed physician order or signed laboratory requisition form for the billed tests. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80157, 80177, 80201, 80162, 80159, and 80173 provided on June 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral lumbar facet injections.
You asked the Plan to pre-approve bilateral lumbar facet injections. You say that you need the injections for relief from your pain. The Plan denied your request. The Plan says the enrollee has not had back pain for more than 3 months.
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 bilateral lumbar facet injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the LCD criteria require that the pain be present for 3 months before interventional therapy is started. The patient has NOT trials of other conservative and physical medicine therapies. The request is 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 bilateral lumbar facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral lumbar facet injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral periapical radiographic image (D0220) provided on December 30, 2020.
You asked the Plan to pay for a comprehensive oral evaluation, and an intraoral periapical radiographic image. You say that you do not want to pay for these services. The Plan denied your request. The Plan says the services are a covered benefit, but you have exceeded the frequency limit.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, and an intraoral periapical radiographic image have not been met. Specifically, the record shows that you had exceeded the frequency limit for the comprehensive oral evaluation prior to this service on February 20, 2019. The record also shows that you had exceeded the frequency limit for the intraoral periapical radiographic images. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), and an intraoral periapical radiographic image (D0220) provided on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ophthalmic biometry provided on December 23, 2020.
You asked the Plan to waive the copayment for the ophthalmic biometry. You say that you should not have a separate copayment for the ophthalmic biometry. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for Vision Care. You have been asked to pay a $20 copayment for the ophthalmic biometry. The ophthalmic biometry falls 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 waive the copayment for the ophthalmic biometry provided on December 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 2, 2020.
You asked the Plan to pay for the home visit. You say that there is a medical necessity pre-established with the patient and the facility. You say that the records prove the need for the services rendered to be paid. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pap test you received on July 16, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the benefit limit was exceeded.
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 copayment for pap tests and pelvic exams once every 24 months. Review of the fie shows that you were provided a pap test on July 16, 2020. This testing is only covered once every 24 months. The records also show that you were provide a covered pap test on June 25, 2019. The requested test is your second in a 24-month period. This test exceeds the benefit limit. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the pap test you received on July 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PCR testing (87631) provided on December 2, 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 Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. We looked at the file and Medicare rules. Per LCD L37713, the requested PCR testing of 6 or more pathogens is not a covered benefit. 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 PCR testing (87631) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services described by current procedural terminology (CPT) codes 99601 and 99602 provided on June 29, 2020.
You asked the Plan to pay for CPT codes 99601 and 99602. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT codes 99601 and 99602 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services. Therefore, we decided that the Plan does not have to pay for the home infusion services described by current procedural terminology (CPT) codes 99601 and 99602 provided on June 29, 2020.