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

We decided that the Plan does not have to waive the copayment for a breast ultrasound (76641) provided October 21, 2019 
You asked the Plan to waive the copayment for the ultrasound. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copay 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 $45 copayment for X-rays. You have been asked to pay a $45 copayment for the ultrasound. The ultrasound falls within the X-rays 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 a breast ultrasound (76641) provided October 21, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Methotrexate 2.5mg tablet medication.
You asked the Plan to pre-approve this medication. You say that this patient has been stabilized on this medication. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Methotrexate 2.5mg tablet medication.
Benefits for this medication 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
You asked the Plan to pre-approve bone marrow aspiration (20939). You say that the requested bone marrow aspiration is medically necessary. The Plan denied your request. The Plan says the requested bone marrow aspiration is not medically necessary.
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 bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found this enrollee is indicated for L4/5 and L5/S1 decompression with interbody fusion. Under consideration is a request for bone marrow aspirate. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the planned lumbar spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate is not medically reasonable and necessary for the approved lumbar spine decompression and fusion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration (20939) have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no enrollment in a clinical trial.
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 the surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from July 2, 2019 through July 19, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that you were there for 7 days not knowing what you had. You say that you don't agree with the charge.The Plan denied your request.The Plan says the copayment 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 $225 copayment per day for days 1-7 and a $0 copayment per day for days 8-365.You have been asked to pay a $1,575 for the inpatient stay. ($225/day x first 7 days = $1,575). The inpatient stay falls within the "Inpatient hospital 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 forthe inpatient stay provided from July 2, 2019 through July 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on June 4, 2019 by an out of network provider, Pro Transport-1.You asked the Plan topay forthe non-emergent ambulance service.You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says you did not request 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 anetwork provider with the Plan. The Plan did not pre-approve the service 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 forthe ambulance services provided on June 4, 2019 by an out of network provider, Pro Transport-1.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvetestosterone gel 1.62% for the enrollee.You asked the Planto pre-approvethe gel. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication does not fall under 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 Plandoes not haveto pre-approvetestosterone gel 1.62% for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September
18, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that this was routine laboratory
work for a routine annual physical and it is supposed to be covered in full. The Plan denied your request. The
Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $15
copayment for in-network Medicare-covered lab tests.
You have been asked to pay a $15 copayment for the laboratory work. The laboratory work falls within
"Outpatient diagnostic tests and therapeutic services and 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 the laboratory work provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee on May 13, 2018.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the claim was submitted after the timely filing limit.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 services was not filed until October 25, 2019. 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 forthe services provided to the enrollee on May 13, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 2, 2019.
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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe urgent care visit provided on November 3, 2019.You asked the Plan to waive the copayment forthe urgent care visit. You say that you went to a walk-in clinic and did not go to urgent care. 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 $65 copayment per visit for Medicare-covered urgently needed services. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The record shows you were billed the urgent carefacility.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 haveto waive the copayment forthe urgent care visit provided on November 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for cystourethroscopy (52000) provided on October 1, 2019.You asked the Plan to pay for cystourethroscopy. You say that the cystourethroscopy performed was distinct from the other proceduresperformed at the time of service and was not inclusive to the vulvar lesion removal or the urethral biopsy. The Plan denied your request. The Plan says CPT code 52000 is not separately reportable with the surgical procedure.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coder to carefully review the casefile and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for cystourethroscopy. Our reviewer says that CPT code 52000 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided include documentation of a Biopsy of urethra (53200) being performed on October 1, 2019. Per NCCI, there is no modifier or circumstance in which both procedures should be paid for when performed on the same patient, on the same date of service by the same provider.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cystourethroscopy have not been met. Therefore, we decided that the Plan does not have to pay for cystourethroscopy (52000) provided on October 1, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay fordrug testing provided on October 22, 2019.You asked the Plan to pay fordrug test. You say that this testing was deemed medically necessary by the ordering physician, and it was not the responsibility of your laboratory to create a treatment plan or have any contact with the enrollee.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test exceeds the maximum frequency of 18 tests per year.The Plan must follow Medicare rules. Medicare rules say that the frequency of presumptive urinary drug testing may be limited to 156 times per year for enrolleeswith 0 to 90 consecutive days ofabstinence or 36 times per year for enrollees with more than 90 consecutive days of abstinence. We looked at the file and Medicare rules.Our review of the rules did not reveal a limitation of 18 tests per year for these services, as cited by the Plan.The Plan has not shown that this test exceeded the frequency limitation for presumptiveurinary drug testingas cited above in the LCD.Based on this information, we decided that Medicare rules for coverage of drug test have been met.Therefore, we decided that the Plan has to pay fordrug testing provided on October 22, 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 newinformation. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil for the enrollee.
You asked the Plan to pre-approve this is medically necessary.. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered 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 Modafinil for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebilateral custom foot orthotics (L3000).You asked the Plan to pre-approvethe foot orthotics. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  The records show that you suffer from Diabetes. However, although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Specifically, you do not have diabetic foot disease. Therefore, we decided that the Plan does not have to pre-approvebilateral custom foot orthotics (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee'smedical status required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on September 24, 2019.
You asked the Plan to pay for drug test. You say that this testing was deemed medically necessary by the ordering physician, and it was not the responsibility of your laboratory to create a treatment plan or have any contact with the enrollee. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test exceeds the maximum covered frequency of 18 tests per year.
The Plan must follow Medicare rules. Medicare rules say that the frequency of presumptive urinary drug testing may be limited to 156 times per year for enrollees with 0 to 90 consecutive days of abstinence or 36 times per year for enrollees with more than 90 consecutive days of abstinence. We looked at the file and Medicare rules. Our review of the rules did not reveal a limitation of 18 tests per year for these services, as cited by the Plan. The Plan has not shown that this test exceeded the frequency limitation for presumptive urinary drug testing as cited above in the LCD. Based on this information, we decided that Medicare rules for coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug testing provided on September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for 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 daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 skilled nursing facility (SNF) care
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted and treated for septic shock related to Fournier's gangrene of the perineum. Surgery and antibiotics were provided, and wound care was initiated including VAC placement. LTACH transfer was requested due to wound care needs. Current documentation shows ongoing IV antibiotics and daily involved wound care which warrants acute care, which could be continued at the current facility. There was no indication from the records that this enrollee would likely require more than 25 additional days of acute care need to justify LTACH. There were no proposed and required services available at the LTACH that were not already being provided and covered in the current acute care facility. Transfer to a lower level of care can be considered soon once there is further improvement. Therefore, this request for LTACH services will be considered not medically necessary at this time.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-approvelong term acute care hospital (LTACH) services.