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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck spine (72125), CT scan of the thoracic spine (72128), and CT scan of the lumbar spine (72131) with myelography.
You asked the Plan to pre-approve a CT scan of the neck spine, CT scan of the thoracic spine, and CT scan of the lumbar spine with myelography. 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 CT scan of the neck spine, CT scan of the thoracic spine, and CT scan of the lumbar spine with myelography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found review of the submitted records shows no physical exam or neurological evaluation. No plain film reports are in the submitted records. There is mention of a planned neurology referral and a nerve conduction study. Absent these sources of medical indication to justify the requested CT myelogram, the medical necessity has not been established. 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 CT scan of the neck spine, CT scan of the thoracic spine, and CT scan of the lumbar spine with myelography have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the neck spine (72125), CT scan of the thoracic spine (72128), and CT scan of the lumbar spine (72131) with myelography.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (95812) provided on May 13, 2019.
You asked the Plan to pay for the electroencephalogram. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service billed.
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 95812 is electroencephalogram (EEG) extended monitoring; 41-60 minutes. We asked our coder 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 electroencephalogram. Our reviewer says that CPT code 95812 does not meet criteria for billing or reimbursement consideration. Our reviewer found documentation consists of an Electromyography being performed during a nonintracranial surgery. Therefore a more appropriate code would apply. 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 electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (95812) provided on May 13, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 27, 2019.
You asked the Plan to pay for genetic test. You say that the treating physician ordered this test as a safe and effective method to aid in evaluation of the enrollee's condition. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this testing code is not covered by Medicare.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on November 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve Dupixent (J3590). You say that you have tried other medications. The Plan denied your request. The Plan says this drug is not covered under your Medicare 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 Dupixent.
Benefits for Dupixent (J3590) 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings.
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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you were medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. Functionally, given your current level, you do not require the IRF level of therapy. You may benefit from further PT and OT, but you do not require an intensive therapy program. The admission is not medically necessary, based on your current functional status and medical stability. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 10,
2020.
You asked the Plan to pay for the drug testing. 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 code G0483 is not supported in the medical record. Specifically, the documentation
submitted did not include a valid physician order/lab requisition form or medical records signed by the ordering
physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare
rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing coded G0483 provided on February 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen (J8499).
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that you would like reconsideration because this drug is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says this drug is not covered for the member's condition by Medicare Part B.
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 Hydrocodone-Acetaminophen (J8499).
Benefits for Hydrocodone-Acetaminophen 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair transportation provided on December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the wheelchair transportation. You say that transportation authorization was not obtained. Please back date an authorization for 12/30/2019. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.
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 wheelchair transportation provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Prolia.
You asked the Plan to pre-approve the tier exception. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says a tier exception cannot be granted for your Part B medication.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Specifically, tier exceptions cannot be granted for Part B drugs. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Prolia.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on January 15,
2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that the Plan says you have a covered
colonoscopy over 10 years and this is your first colonoscopy. 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 $175
copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center (ASC).
You have been asked to pay a $175 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The medical record shows that a polyp was found and removed during the
colonoscopy which makes the colonoscopy diagnostic in nature.
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 colonoscopy provided on January 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the medical services (99071 and 80305) provided on August 19, 2019.
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The documentation provided in the case file does not support that the treating physician had an inactive license on the date of service in question. Review of the Missouri Division of Professional Registration website, the provider at issue in this case has an active Missouri medical license. No other documentation was submitted to support that the provider is prohibited from billing Medicare or Medicare health plans for services rendered. As such, the Plan's denial is not substantiated in this case. Therefore, we decided that the Plan has to pay for the medical services (99071 and 80305) provided on August 19, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures and activities (97110, 97530 and 97112) provided on January 7, 2020.
You asked the Plan to pay for the therapeutic procedures and activities. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. The CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. The CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We asked our coder 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 therapeutic procedures and activities. Our reviewer says that CPT codes 97110, 97530 and 97112 do not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted does not indicate the date of service, specific therapeutic exercises or time spent.
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 therapeutic procedures and activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedures and activities (97110, 97530 and 97112) provided on January 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF care. You say that an inpatient skilled nursing facility admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF 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 pre-approve SNF care. Our reviewer says that an inpatient skilled nursing facility admission is not medically necessary. Our physician reviewer found that the enrollee does not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 140mg/ml Aimovig Autoinjector.
You asked the Plan to pre-approve the Aimovig Autoinjector. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B.
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 140mg/ml Aimovig Autoinjector.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you were having a
diabetic issue. An ambulance was called for you and they gave you an IV to help stabilize your glucose levels.
You say that once you were stabilized there was no reason to go to the hospital. You stated that you should
avoid being transported to the hospital if possible due to Covid-19. 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 March 20, 2020. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for catheter supplies (A4351, A4332) provided
January 22, 2020 to March 27, 2020.
You asked the Plan to waive the copayment for the catheters and supplies. You say that the coinsurance should
be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for prosthetic devices and medical supplies.
You have been asked to pay a 20% coinsurance for the catheters and supplies. The catheters and supplies fall
within the prosthetic devices and medical 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 catheter supplies (A4351, A4332) provided January 22, 2020 to March 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extremity studies and a duplex scan provided on December 18, 2019.
You asked the Plan to pay for the extremity studies and a duplex scan. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 extremity studies and a duplex scan provided on December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 6, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 6, 2019.