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

We decided that the Plan does not have to pre-approve Synvisc injections.
You asked the Plan to pre-approve Synvisc. You say that the Synvisc is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Synvisc. Our reviewer says that coverage criteria has not been met. Our physician reviewer found there was no trial of the plan preferred agents. The record shows no reason the plan preferred drugs would be contraindicated for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve knee surgery 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 that the services were not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with persistent right knee pain with associated swelling for months. Functional limitations are noted in weight bearing activities. Clinical exam findings are consistent with imaging evidence of a right knee medial meniscus tear, posterior horn. There is radiographic evidence of very slight right knee medial joint space narrowing with minimal osteophyte (degenerative changes.). Reported conservative treatment, including activity modification, NSAIDs, analgesics, and physical therapy, has failed to provide improvement. Current evidence based medical literature supports surgical intervention at this time based on subjective complaints, physical exam, imaging findings, and failed conservative treatment. Therefore, the requested right knee surgery is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have been met.Therefore, we decided that the Plan has to pre-approve knee surgery for the enrollee.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy. 
 
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation.
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 the services are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that the PC of codes with a PC/TC indicator of 8 is only payable when performed at an inpatient hospital setting. We looked at the file and Medicare rules. The file shows that billed procedure code 85060 was not performed in an inpatient hospital setting. The code has a PC/TC indicator of 8; therefore, the PC is not separately payable. 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 blood smear interpretation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nebulizer with compressor (E0570).You asked the Plan to pre-approve a nebulizer. You say that this is medically necessary.The Plan denied your request. The Plan says not have an appropriate diagnosis.The Plan follows Medicare rules. Medicare rules say that a  small volume nebulizer is covered for the above listed indications. 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 nebulizer. Our reviewer says that the requested nebulizer has not been shown to be medically necessary at this time. Our physician reviewer found the medical record does not mention a diagnosis of asthma, chronic obstructive pulmonary disease, or obstructive lung disease, or any other diseases that would require administration of a medication via the inhalation route. There are no pulmonary function data. It is unclear what medication is to be nebulized.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 nebulizer have not been met.Therefore, we decided that the Plan does not have to pre-approve a nebulizer with compressor (E0570).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 16, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration because it takes 30 minutes to set up the machine and the perfusionist is required to remain in the operating room through the length of the procedure. The Plan denied your request. The Plan says payment for this service is the responsibility of the facility to any vendor.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for anesthesia. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-referred.
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 anesthesia provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MyTest full hereditary cancer gene panel provided to the enrollee on February 15, 2019.
You asked the Plan to pay for the panel. You say that the enrollee would benefit from this due to a family history of cancer. The Plan denied your request. The Plan says this is a buccal swab test which is not FDA-approved for cancer management of any type of cancer.
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 pay for the panel. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there is limited documentation provided - only the lab result. No provider records have been submitted for review. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). In general, panel testing which is unrelated to a specific diagnosis or treatment, and appears to be for general screening purposes, is not considered to be medically necessary or reasonable.
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 panel have not been met. Therefore, we decided that the Plan does not have to pay for the MyTest full hereditary cancer gene panel provided to the enrollee on February 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection
You asked the Plan to pay for the provided injection. You say that the services were provided in good faith. The Plan denied your request. The Plan says the procedure code is not valid for Medicare purposes.
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 S0220 is Injection, bupivicaine hydrochloride, 30 ml. We find that CPT code S0220 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the provided injection have not been met. Therefore, we decided that the Plan does not have to pay for the bupivicaine hydrochloride injection
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from December 31, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the claim was billed with an invalid type of bill for a non-participating Home Health provider.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim includes an inappropriate type of bill code for home health services.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 12, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgentcareor if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 physician's services provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on January 24, 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 the services are not separately payable.
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility. Therefore, we decided that the Plan does not have to pay for the special pump services rendered on January 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ultratrak Test Strips.
You asked the Plan to pre-approve the test strips. You say that the test strips are medically necessary. The Plan denied your request. The Plan says the requested test strips are not a plan preferred brand.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands. 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 test strips. Our reviewer says that rules for coverage were not met. Our physician reviewer found the medical records do not show any reason why the enrollee cannot use the plan preferred test strips.
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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Ultratrak Test Strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift.
You asked the Plan to pre-approve a seat lift. You say that this is medically necessary. The Plan denied your
request. The Plan says that there are no records.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed above are met.
We looked at the file and Medicare rules. Your provider has not provided any records confirming you have met
the above criteria for coverage. Based on this information, we decided that Medicare rules for coverage of a
seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided on December 12, 2019.
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. In this case, the CPT Code Manual definition of code 80307 is drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service. We find that CPT code 80307 is not supported in the medical record. Specifically, the documentation does not include documentation of drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 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 80307 provided on December 12, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits (G0151).
You asked the Plan to pre-approve 8 additional PT visits. 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. The rules say that Medicare pays for medically necessary outpatient therapy. 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 8 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the requested therapy is generally not accepted as specific and effective therapy for your condition. The PT documentation shows that your overall functional status will likely not change. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have had extensive therapy and have met your goals. You should be able to transition to an independent home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional physical therapy (PT) visits (G0151).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided by a physician on October 4, 2019. You asked the Plan to waive the copayment for outpatient lab work. You say that you think this is part of a
scam. You say that you did not request to pee in a cup. The Plan denied your request. The Plan says the correct
copayment has been 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 $10 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay $3.48 which is less than your copayment amount of $10 for outpatient lab work. When other services are provided during an office visit, additional copayments can be applied; therefore, the correct copayment has been applied. Outpatient lab work falls within the outpatient diagnostic tests/laboratory tests 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 outpatient lab work provided by a physician on October 4, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography angiography (CTA) of heart.
You asked the Plan to pre-approve CTA of the heart. You say that this imaging is medically necessary. The
Plan denied your request. The Plan says that Medicare coverage criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that CTA scans are covered only when they are
medically necessary.
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 CTA of the heart. Our reviewer says
that Medicare coverage criteria are met. Our physician reviewer found based upon the entire picture and the
subjective language concerning high and intermediate risk of abnormality, in this case the requested CTA of
the heart is indicated and is overall in the best interest of the enrollee. We looked at this physician's review, the
file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTA of the
heart have been met. Therefore, we decided that the Plan has to pre-approve computed tomography
angiography (CTA) of heart.
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.