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

We decided that the Plan does not have to pre-approveuse of Ilumya.You asked the Plan to pre-approveIlumya. You say that this is the appropriate therapy for your condition.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Remicade or Inflectra and Stelara before it will approve Ilumya.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 PartB 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 Ilumya. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Ilumya. Our physician reviewer found the record does not show that you have tried and failed the Plan's preferred drugs of Remicade or Inflectra and Stelara. There is no documentation indicating that these drugs would likely be less effective and/or likely have adverse effects for you.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Ilumya.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the 16-day inpatient hospital admission
provided from May 16, 2020 to May 31, 2020.

You asked the Plan to waive the copayment for the inpatient hospital admission. You say that you should not
have a copayment as you had already met your out-of-pocket maximum for the year. The Plan denied your
request. The Plan says the out-of-pocket maximum counts only medical services (no drug costs), and inpatient
hospital admissions are subject to a $225 copayment for each of the first 5 days of a single admission.

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 for each of the first five days of an inpatient hospital admission. Your contract also states that the
$3,000 out-of-pocket maximum applies to medical services, or those covered by Medicare Part A and B. Drug
services are covered by Part D and have a separate out-of-pocket cost limit.

You have been asked to pay a $225 copayment for each of the first five days for inpatient hospital admission
($225 x 5 = $1,125). An inpatient hospital admission falls within the inpatient hospital care benefit category.
The record shows that you did not meet your out of pocket maximum for Medicare Part A and B medical
services. 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 16-day inpatient hospital admission
provided from May 16, 2020 to May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acupuncture services provided September 11, 2020 to October 1, 2020.You asked the Plan to pay forthe acupuncture services. You say that you would like to be reimbursed for your acupuncture visits. This is expensive at $65 per visit. You believe that this treatment is medically necessary to treat your chronic backpain.The Plan denied your request. The Plan says this service is not covered under the plan benefits.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically,the health plan contract says that acupuncture is not covered under any condition.Therefore, we decided that the Plan does not have to pay forthe acupuncture services provided September 11, 2020 to October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout of area dermatology services.You asked the Plan to pre-approvethe out of area dermatology services. You say that you go to Florida every year for 4 months or so. You say that you were recently diagnosed with squamous cell condition and your dermatologist in Massachusetts will not be able to see you for a while. You say that the requested treatment should be covered. You say that it was implied the denial and appeal was a formality and that it would be OK to see the doctor in Florida.The Plan denied yourrequest. The Plan says there are in-network providers in the service area who can provide the surgery services needed.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  We looked at the file and Medicare rules. The records show that the need for the dermatology services was not unforeseen, and that you were aware of the need for treatment prior to leaving the service area. Based on this information, we decided that Medicare rules for coverage of out of area care have not been met.Therefore, we decided that the Plan does not have to pre-approveout of area dermatology services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fornon-emergent ambulance transport (A0428, A0425) to a physician's office on September 30, 2020.You asked the Plan to pay fornon-emergent ambulance transport. You say that physician's offices have been determined to be a Medicare-covered destination during the Public Health Emergency.The Plan denied your request. The Plan says rules for payment have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. There is no documentation in the case record to support that the non-emergent ambulance transport was related to aconfirmed or suspected diagnosis of COVID-19. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.Therefore, we decided that the Plan does not have to pay fornon-emergent ambulance transport (A0428, A0425) to a physician's office on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiogram provided in an
outpatient hospital setting on June 17, 2020.
You asked the Plan to waive the copayment for the echocardiogram provided in an outpatient hospital setting.
You say that you feel the enrollee should not be responsible for this cost share amount and you would like the
Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received
echocardiogram services provided in a hospital-based facility on the date of service at issue in this appeal. The
Plan says that the correct copayment has applied per the enrollee's contract with the Plan.
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 $400 copayment for Outpatient diagnostic tests.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received an
echocardiogram provided in a hospital-based facility on June 17, 2020. The enrollee has been asked to pay a
$400 copayment for the echocardiogram provided in an outpatient hospital setting. The echocardiogram
provided in an outpatient hospital setting falls within the Outpatient diagnostic tests benefit category. This
means that the enrollee has been asked to pay the correct amount based on the enrollee's contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay when the enrollee enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for the echocardiogram provided in
an outpatient hospital setting on June 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ultrasound (76770) provided on August 12, 2020.You asked the Plan to pay forthe ultrasound. You say that you would like reconsideration because this service was billed with the correct place of service code.The Plan denied your request. The Plan says this claim was billed with an inappropriate place of service code.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.We find that CPT code 76770 is not supported in the record. Specifically,the record indicates that the member was registered inpatient on the billed date of service. Therefore, it is inappropriate to bill this service with an outpatient place of service code. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met.Therefore, we decided that the Plan does not have to pay forthe ultrasound (76770) provided on August 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvetwelve additional physical therapy visits.You asked the Planto pre-approvethe visits. You say that this is medically necessary.The Plandenied your request. The Plansaysthe unique skills of a physical therapist are not required to safely and effectively provide ongoing treatment.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 the visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for your condition. You have had extensive therapy for your condition, and the documentation does not indicate that the functional level requires  the ongoing unique skills of a professional therapist  to safely and effectively provide treatment, or  that the services can be safely and effectively performed only by a therapist, or  under the supervision of a therapist. You have been compliant in a 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 the visits have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetwelve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe testing services provided on February 17, 2020.You asked the Plan to pay forthe testing services. You say that the testing enables physicians to deliver personalized cancer care.The Plan denied your request. The Plan says coverage of comprehensive genomic profile testing is limited to one test per specimen.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 looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure.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 pay forthe testing services provided on February 17, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. The Plan denied your request. The Plan says the submitted information shows no history of osteoporosis-related fracture, and the use of Zoledronic Acid was not addressed as inappropriate.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drug Zoledronic Acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). Our reviewer found that there is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer also found that the enrollee does not have a history of osteoporotic fracture.  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-approveProlia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent and/or steroid,
transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level (CPT Code
64483).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your
request. The Plan says they did not receive any medical records.
The Plan follows Medicare rules. 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 service have not been met. We did not
receive any medical records to verify the Medicare criteria have been met for the enrollee to have the service
performed. Therefore, we decided that the Plan does not have to pre-approve injection(s), anesthetic agent
and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single
level (CPT Code 64483).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for DRG 190 for Acute Respiratory Failure for services provided on June 30, 2020, through July 2, 2020.
You asked the Plan to pay for DRG 190. You say that you would like reconsideration because this code is supported due to the member's Acute Respiratory Failure. The Plan denied your request. The Plan says there is no documentation available to support this level of coding.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 190 is defined as Chronic Obstructive Pulmonary Disease with MCC. In this case, you billed the services provided June 30, 2020, through July 2, 2020 with DRG 190. 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 DRG 190. Our reviewer says that the records do not support the billed DRG 190. Our physician reviewer found the review indicates that the member presented with increasing dyspnea on exertion, one desaturation to 88% was noted, placed on 3L. Not noted here is what her baseline is. She stabilized on O2 supplementation and was evaluated for home O2. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 190. Therefore, we decided that the Plan does not have to pay for DRG 190 for Acute Respiratory Failure for services provided on June 30, 2020, through July 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone density study provided on August 27, 2020.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says screening bone densitometry is not indicated for a female without risk factors.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 testing  at issue in this appeal was requested for screening purposes. In this case, there is insufficient records to show that the enrollee was at risk of losing bone mass, or at risk of osteoporosis. Medicare does not cover this testing for screening purposes.Therefore, we decided that the Plan does not have to pay forthe bone density study provided on August 27, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided from June 6, 2020, through June 12, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $325 copayment per day, for days 1-5 and $0 for additional hospital days, for in-network Medicare-covered inpatient hospital care provided. You have been asked to pay $1,625 ($325 copayment x 5 days) for the Medicare-covered inpatient hospital care provided. 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 copaymentfor the inpatient hospital care provided from June 6, 2020, through June 12, 2020.Your complaint about this inpatient stay being a result of an infection from an initial surgery is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the coinsurance for the hip arthroplasty surgery (27130) provided from August 24, 2020, through August 25, 2020.
You asked the Plan to adjust the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered outpatient hospital visit. You have been asked to pay $2,658.05 (Plan allowed amount of $13,290.24 x 20% coinsurance) for the outpatient surgery provided. Although, you received a letter of approval from the Plan for coverage of an inpatient admission for these dates of service in question, the claim was submitted by the provider for payment of outpatient surgery. 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 adjust the coinsurance for the hip arthroplasty surgery (27130) provided from August 24, 2020, through August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on August 10, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. Medicare rules say that NGS panels are covered when specific criteria are met.We looked at the file and Medicare rules. The file shows that the enrollee does not have a diagnosis of recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 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 forthe laboratory services rendered on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from February 4, 2020, through July 7, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not payable as they have been billed incorrectly.
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 S9328 is not supported in the medical record. Specifically, CPT code S9328 has a status indicator of I and will not be paid by Medicare. These services should be reported with a code that is recognized by Medicare. 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 home infusion therapy services (S9328) provided from February 4, 2020, through July 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVumerity capsules.You asked the Plan to pre-approveVumerity capsules. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Vumerity 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-approveVumerity capsules.Benefits for Vumerity capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights