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

We decided that the Plan does not have to pay for the medical services provided on June 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for clinic services. You say that the enrollee self-referred to the clinic. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 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 the medical services provided on June 3, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator provided on June 9, 2020.

You asked the Plan to pay for the neuromuscular stimulator (E0745). You say that the device was medically necessary. The Plan denied your request. The Plan says medical necessity of the device is not supported in the medical record.

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 shipping date is March 5, 2020, the delivery date is March 9, 2020 but the claim date is June 9, 2020. 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 the neuromuscular stimulator provided on June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scans (71259, 74176) provided on March 10, 2020.

You asked the Plan to pay for CT scans. You say that these services are documented. The Plan denied your request. The Plan says the records do not include the enrollee's name.

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 71259 and 74176 are not supported in the medical record. Specifically, the submitted medical records do not include a patient name or other identifying information to verify that the services at issue were performed on the enrollee. Based on this information, we decided that Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) scans (71259, 74176) provided on March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided.

You asked the Plan to pay for the initial comprehensive preventive medicine evaluation and management. You say that this exam should be covered.The Plan denied your request. The Plan says you had a routine physical exam this year already.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at this physician's review, the file, and Medicare rules. The record shows you received a preventative screening from a different provider. Based on this information, we decided that Medicare rules for coverage of these condcomprehensive preventive medicine evaluation and management have not been met.Therefore, we decided that the Plan does not have to pay for the physician services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator.

You asked the Plan to pre-approvethese 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. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 oxygen-dependent chronic obstructive pulmonary disease (COPD) treated with oxygen. There is no significant hypercarbia on arterial blood gas analysis. Sleep study revealed mild obstructive sleep apnea; there was no significant oxygen desaturation during sleep. Based on the documentation provided and the applicable Medicare guidelines, continuation of the non-invasive home ventilator is 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee.

You asked the Plan to pay foran inpatient level of care. You say that inpatient admission was medically necessary.The Plan denied your request. The Plan says the enrollee did not have prior authorization and the records do not show inpatient admission was necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. The medical records provided specifically state "Patient denies anxiety, depression, suicidal ideation. No aggressive or self-harm behaviors noted." Based on this information, we decided that Medicare rules for coverage of an inpatient level of care have not been met.Therefore, we decided that the Plan does not have to pay forinpatient mental health care provided to the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on June 20, 2020.

You asked the Plan to pay for Guardant360 testing. You say that the enrollee's treating physician ordered this testing to determine if there was a more effective therapy to treat the enrollee's condition. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed with the appropriate coding.

The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with CPT code 81479 for date of service June 20, 2020. 

We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on June 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Molecular pathology procedure services provided March 11,
2019.
You asked the Plan to pay for Molecular pathology procedure services. You say that please see attached for
reconsideration. This was originally filed and paid and due to an audit determined 88381 was bundled and
correct claim was filed. The Plan denied your request. The Plan says the claim was received 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 Molecular pathology procedure services was not filed until July 13, 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 Molecular pathology procedure services provided
March 11, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for podiatry office visits provided on July 11, 2019, to
September 4, 2019.
You asked the Plan to waive the copayment for office visits. You say that you disagree with the copayments as
charged. The Plan denied your request. The Plan says that the copayment applied correctly in this case.
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 case record was forwarded to use with an Evidence of Coverage
(EOC) from 2020. However, we needed an EOC from 2019 in order to make our decision regarding these
copayments. We requested a copy of the 2019 EOC several times but it was not received. Accordingly, we
cannot verify the correct copayment was charged without the 2019 EOC. Therefore, we decided that the Plan
has to waive the copayment for podiatry office visits provided on July 11, 2019, to September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs close supervision for strengthening with physical and occupational therapies. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that the enrollee appears to be stabilizing, but requires additional short term acute care services to help further stabilize the enrollee which can safely be completed in the current facility and are likely to not exceed an additional 24 days. The enrollee does not require services in the LTACH that are not already available at the current facility. There are no services at the LTACH that are not already available and covered at the current facility. 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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections (64490, 64491, 64492) provided 
October 7, 2019. 
 
You asked the Plan to pay for the facet joint injections. You say that the services were medically necessary. 
The Plan denied your request. The Plan says documentation does not support the billed services. 
 
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 code 64490, 64491, 64492 is not supported in the medical record. Specifically, operative 
notes document a Cervical Medial Branch Radiofrequency Ablation was performed. Documentation does not 
support CPT 64490. Since the primary code is not supported, the add-on codes are also not supported. Based on 
this information, we decided that Medicare rules for coverage of the facet joint injections have not been met. 
Therefore, we decided that the Plan does not have to pay for facet joint injections (64490, 64491, 64492) 
provided October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve a therapeutic continuous glucose monitor and supplies. You say that the 
requested equipment is medically necessary. The Plan denied your request. The Plan says you do not meet all 
the required criteria for coverage of this equipment. 
 
The Plan must follow Medicare rules. Medicare has specific coverage criteria for this type of equipment. Those 
criteria are stated above. According to the medical records provided by your physician, you are not currently 
using insulin and you do not meet all the required criteria stated above. Medicare coverage criteria are not met. 
Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and 
supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Prolia. Our reviewer says that Prolia is
not medically reasonable and necessary for the enrollee. Our physician reviewer found you have not tried and
failed the required drug(s). Our reviewer also found that there is no indication that the Plan's required drug(s)
would likely be less effective and/or likely have adverse effects for you.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on July 24, 2020. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services were done as 
part of your annual wellness exam, so there should not be a separate copayment. The Plan denied your request. 
The Plan says the annual wellness exam does not include lab services.  The Plan says that a separate copayment 
for the lab services was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for lab services.  
 
You have been asked to pay a $10 copayment for the lab services. You contract with the Plan explicitly states 
that if you receive additional services (such as lab services) during your annual wellness exam that a separate 
copayment will apply. 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 lab services you received on July 
24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not 
require intense treatment of acute medical issues, or special equipment for rehab. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our physician reviewer found 
that the enrollee was admitted to the acute hospital for surgical treatment of a hip fracture after a fall. The 
enrollee's medical problems are stable. The complexity of his nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
medical record supports a need for physical and occupational therapy, but it does not support a need for an 
intensive rehabilitation therapy program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyepti. 
 
You asked the Plan to pre-approve Vyepti. The Plan denied your request. The Plan says the drug is not covered 
under the Part B benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Vyepti.  
 
Benefits for Vyepti 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 6, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization.  
 
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 
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 subsequent nursing facility care provided on August 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy. 
 
You asked the Plan to pre-approve Trelegy. You say that the enrollee has been compliant and benefiting from 
Trelegy. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient 
prescription drugs. 
 
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 Trelegy.  
 
Benefits for Trelegy 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the physician services for outpatient heart 
rehabilitation (93798) provided on May 18, 2020, to May 22, 2020. 
 
You asked the Plan to waive the coinsurance for the physician services for outpatient heart rehabilitation. You 
say that you thought there would be no coinsurance for the services provided. The Plan denied your request. 
The Plan says the coinsurance applied correctly in this case. 
 
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 cardiac rehabilitation services.  
 
You have been asked to pay a 20% coinsurance for the physician services for outpatient heart rehabilitation. 
The services provided  fall within the cardiac rehabilitation services 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 physician services for outpatient heart rehabilitation (93798) provided on May 
18, 2020, to May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth services provided on May 20, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for telehealth services. You say that prior authorization should not be required for 
telehealth services. 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 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 telehealth services provided on May 20, 2020, by 
an out-of-network (OON) provider.