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

We decided that the Plan does not have to pre-approve Denosumab (Prolia) for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says there is no documentation of supplemental calcium.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our physician reviewer found that the enrollee is noted to have osteoporosis based. The enrollee is noted to be taking vitamin D, but not calcium. There is no documentation of laboratory calcium or vitamin D levels. The enrollee is noted to have been previously intolerant of anti-resorptive medication, but which medication(s) and the nature of the intolerance are not noted. Such medications are not noted on the enrollee's allergy list. The documentation is insufficient to show that the requested drug is currently 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Denosumab (Prolia) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to providePositron Emission Tomography (PET) Myocardial Imaging (78492).You asked the Plan to providethe PET Cardiac Imaging. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not beenmet.The Plan must follow Medicare rules. Medicare rules say that PET 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 provide the PET Cardiac Imaging. Our reviewer says that the requested PET Scan is reasonable and necessary. Our physician reviewer found the enrollee has known Coronary Artery Disease and poor exercise tolerance. Based on coverage criteria, pharmacologic nuclear stress testing is indicated in patients who cannot perform 4 METS of activity or have symptoms which may be suggestive of ischemia. The patient has dyspnea and fatigue and poor exercise tolerance. The enrollee fits the criteria for preoperative assessment before surgery. Since PET can offer better diagnostic accuracy, it is both reasonable and medically necessary to risk stratify this patient before her planned non-cardiac surgery.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 PET Cardiac Imaging have been met.Therefore, we decided that the Plan has to providePositron Emission Tomography (PET) Myocardial Imaging (78492).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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe x-ray provided on October 11, 2019.You asked the Plan to waive the copayment forthe x-ray . You say that you should not be responsible for the copayment because you were not told you would owe anything. 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 $50 copayment for each in-network Medicare-covered x-ray service. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $50 copayment for the x-ray.You have been asked to pay a $32.85 copayment for the x-ray. The x-ray falls within the "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 forthe x-ray provided by on October 11, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta capsules.
You asked the Plan to pre-approve Nuedexta capsules. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Nuedexta capsules are not covered under the enrollee's Medicare Part B benefit.
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 Nuedexta capsules.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nuclear stress test for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a nuclear stress test is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has no documented coronary disease, no symptoms of angina, a normal cardiac physical exam and a stable unchanged electrocardiogram with mild nonspecific abnormalities. The records do not support that the requested repeat nuclear stress test is reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a nuclear stress test for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from February 25, 2019 to May 28, 2019.You asked the Plan to pay forhome infusion therapy. You say that you should be reimbursed for these services.The Plan denied your request. The Plan says this 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.We find that CPT code S9328is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided from February 25, 2019 to May 28, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 19, 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 procedure code 88812 is not separately payable.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.The provider submitted a claim for procedure code 88812-26. The file does not show that the services were rendered in a separate payment locality; therefore, billing of the PC with modifier -26 is not allowed.Therefore, we decided that the Plan does not have to pay forthe laboratoryservices rendered on September 19, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe oral hygiene instructions (D1330), the observation visit (D9430), gingival irrigation (D4921) for all 4 quadrants, the comprehensive oral evaluation (D0150), prophylaxis (D1110), and the intraoral periapical x-ray (D0220) provided on September 24, 2019.You asked the Plan to pay forthe dental services. You say that you have a history of periodontal disease. You say that you were advised to have a minimum of 2 cleanings per year. You also say that when you signed on with the Plan, you were advised you were permitted to 2 cleanings per year.The Plan denied your request. The Plan says that the frequency limit for prophylaxis and the oral evaluation have been exceeded.The Plan also says the oral hygiene instructions, the observation visit, gingival irrigationand the periapical x-ray are not listed as covered services.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.Though the Plan offers a dental benefit in excess of Medicare coverage and the oral evaluation and prophylaxis are covered services, the frequency limits have been reached. The record shows that the Plan previously paid for these services for date of service February 14, 2019. Additionally, oral hygiene instructions, the observation visit, gingival irrigation, and the periapical x-ray are not covered services.Therefore, we decided that the Plan does not have to pay forthe oral hygiene instructions (D1330), the observation visit (D9430), gingival irrigation (D4921) for all 4 quadrants, the comprehensive oral evaluation (D0150), prophylaxis (D1110), and the intraoral periapical x-ray (D0220) provided on September 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not require daily skilled services.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.Continued SNF services beyond February 5, 2020 were requested. 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 services. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. You are consistently ambulating more than 100 feet, and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0482 provided on July 18, 2019.You asked the Plan to pay forthe 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 G0482 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed.We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition 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 forthe drug testing coded G0482 provided on July 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion. You say that you want a non-biased opinion. The Plan denied your request. The Plan says there are in-network providers available for a second opinion.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea tertiary level referral.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is an approved authorization for a non-tertiary provider. 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 referral. Our reviewer says that the requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no need for an out-of-plan referral. The service is available in-plan.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 referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tertiary level referral.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 12,2019 by OONprovider.You asked the Plan to pay for the ambulance services. You say that the skilled nursing facility set up the ride and you were not aware the service was not authorized.The Plan denied your request. The Plan says prior authorization was not requested.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 services at issue in this appeal. 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 for the ambulance services provided on July 12,2019 by OONprovider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on July 23, 2019.You asked the Plan to pay for the laboratory testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 laboratory testing at issue in this appeal 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 testing provided on July 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on September 23, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. Thismeans that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0648) provided to the enrollee on September 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chronic care management provided on October 31, 2019 by an out of network (OON) provider.You asked the Plan to pay for chronic care management. 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 for these services. The Plan says that there are in-network providers available 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 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 chronic care management provided on October 31, 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 genetic testing rendered on June 3, 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 screening tests are not covered.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 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 genetic testing rendered to on June 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable control system for a power wheelchair.You asked the Plan to pre-approvethe expandable control system. The Plan denied your request. The Plan says the enrollee is able to control the approved power options with their own switches.The Plan follows Medicare rules. Medicare rules say that power wheelchair options and accessories are only covered under certain medical 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 the expandable control system. Our physician reviewer found that the enrollee has multiple comorbid conditions with impairment of mobility.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost-sharing amount applied to Orthovisc injection services.
You asked the Plan to adjust the cost-sharing amount applied to the Orthovisc injection services. You say that the drug in dispute is medically necessary. The Plan denied your request. The Plan says Part B drugs are not eligible for tier exceptions
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 the enrollee must pay a 20% coinsurance for Medicare Part B Covered Drugs. The enrollee has been quoted a 20% coinsurance for the Orthovisc. the Orthovisc is a Medicare Part B covered drug and falls within the Medicare Part B Covered Drugs benefit category. This means that the enrollee has been quoted the correct cost-sharing amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to adjust the cost-sharing amount applied to Orthovisc injection services.