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

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150, 87500, 87640,
87653, 87798, 87799) provided to the enrollee on January 22, 2021.

You asked the Plan to pay for the laboratory services. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.

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 test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 87150, 87500, 87640, 87653, 87798, 87799) provided to the enrollee on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 23, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99204 is 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 99204 is Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. 

We find that CPT code 99204 is not supported in the medical record. Specifically, the file shows that the enrollee was seen by this provider on March 1, 2019; therefore, a new patient office visit does not apply. 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 pay for the office visit rendered on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on February 11, 2021.

You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and bitewing radiographic images. You say that you want the claim to be reimbursed according to the out-of-network guidelines. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt-Out providers.

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 periodic oral evaluation, a teeth cleaning, and bitewing radiographic images have not been met. Specifically, services were provided by an Opt-Out provider. The Plan does not cover dental services when provided by an Opt-Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and bitewing radiographic images (D0274) provided on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code(s): 81105, 81112, 81226,
81227, 81230, 81240, 81241, 81291, 81355, 81479) provided to the enrollee on January 12, 2021.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied
your request. The Plan says Medicare denies coverage when a laboratory assays two or more genes in a patient
in parallel. The Plan states those two or more genes will be considered part of the same panel and a panel
constitutes a single procedural service, so one CPT code must be submitted for the panel.

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 [Enter billing code at issue (e.g. 43856, K0002, etc.)] is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. If a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory testing (CPT code(s): 81105, 81112, 81226, 81227, 81230, 81240, 81241, 81291, 81355, 81479) provided to the enrollee on January 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine for the enrollee.

You asked the Plan to pre-approve this drug. You say that the patient is stable on this medication. The Plan denied your request. The Plan says that this is covered under Part D.

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 Cyclobenzaprine for the enrollee.

Benefits for this drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 11, 2021.

You asked the Plan to pay for lab tests. You say that the treating physician made a professional determination of medical necessity. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because records are needed in order to determine the clinical utility of this testing but were not provided.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab testing billed on this claim. Without this information, it cannot be determined whether this testing was ordered for covered purposes. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on January 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on June 13, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 32555-RT is 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 32555-RT is thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance. 

We find that CPT code 32555-RT is not supported in the medical record. Specifically, the documentation shows that left sided thoracentesis was performed, not right. 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 pay for the surgical services rendered on June 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy services. The Plan denied your request. The Plan says the physical therapy services can be received from providers in-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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on December 10, 2020 by an out of network (OON) provider.

You asked the Plan to pay for pathology services. You say that prior authorization was not possible. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these 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 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 had network providers available who could have provided 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 pathology services provided on December 10, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81407, 81408, and 81479) provided to the enrollee on October 3, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules say that this policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Medicare denies coverage for all cardiovascular risk assessment testing / panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular-respiratory disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81407, 81408, and 81479) provided to the enrollee on October 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of bone marrow aspirate for use as a bone graft substitute. Our physician reviewer found that your condition does not meet criteria for coverage of these services. 

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-approve bone marrow aspirate.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor (CGM) and supplies (K0553 and K0554).

You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a CGM and supplies. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do have diabetes, but you are not on insulin. 

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 CGM and supplies have not been met. Specifically, you are not being treated with insulin. This means you do not meet the criteria for a CGM and supplies. Therefore, we decided that the Plan does not have to pre-approve a Free Style Libre continuous glucose monitor (CGM) and supplies (K0553 and K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular stimulator.

You asked the Plan to pre-approve the requested service. You say that the goal is to help alleviate the enrollee's current pain. The Plan denied your request. The Plan says the requested device is not covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. Acupuncture for auricular stimulation does not meet the definition of reasonable and necessary. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular stimulator.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Teprotumumab-trbw.

You asked the Plan to pre-approve Teprotumumab-trbw. 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 Teprotumumab-trbw. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that corticosteroids 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 Teprotumumab-trbw have not been met. Therefore, we decided that the Plan does not have to pre-approve Teprotumumab-trbw.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81238, 81286, 81410, 81411, and 81439) provided to the enrollee on September 20, 2020.

You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules say that this policy denies coverage for all CV risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The enrollee had cardiovascular risk assessment testing on September 20, 2020. Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing (CPT code(s): 81238, 81286, 81410, 81411, and 81439) provided to the enrollee on September 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 28, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you feel that services should have been rendered at the urgent care facility and not in the emergency room. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. The medical records show that the enrollee received emergency care on February 28, 2021. Therefore, they are responsible to pay the $90 copayment. 

The enrollee has been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on February 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need 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 in the Medicare rules section. 

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for dizziness and shortness of breath associated with a ventricular arrhythmia. Your medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract
specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120)
provided to the enrollee on January 28, 2021.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the enrollee are not a benefit. The Plan states that no description of the diagnosis of microhematuria was submitted by any provider.

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 test at issue in this appeal, the laboratory testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) provided to the enrollee on January 28, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast lift with implant removal and replacement.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are cosmetic and not medically necessary.

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 Plan states that the services are not medically necessary; however, no medical records were received with the case file. Maximus requested medical records from the Plan but a response was not received. Therefore, we decided that the Plan has to pre-approve breast lift with implant removal and replacement.

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.