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

We decided that the Plan does not have to pre-approve Aranesp for the enrollee. You asked the Plan to pre-approve Aranesp. The Plan denied your request. The Plan says erythropoetin stimulating agents aren't indicated when chemotherapy is intended to cure cancer, rather than as palliative treatment. The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aranesp. Our physician reviewer found that the enrollee has a diagnosis of anemia due to antineoplastic chemotherapy. The enrollee was diagnosed with IgG lambda myeloma. The anemia is secondary to treatment and is disease-related. An iron panel was within normal limits. Aranesp was to be considered if the enrollee's hemoglobin consistently dropped to less than 10 g/dL. This was to be monitored. On June 9, 2020, the hemoglobin was 9.5 g/dL. The requested use of Aranesp is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approvedmedical journal. The documentation does not support that Aranesp is medically reasonable and necessary for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Mirena IUD.
You asked the Plan to pre-approve the Mirena IUD. You say that you have been on Mirena for 25 years. You say that you have adverse reactions to other forms of birth control. You say that your provider and insurance company advised that Mirena is not covered. The Plan denied your request. The Plan says they confirmed with the provider that Mirena was requested for the use of contraception and not a medical condition. The Plan says that Mirena for the purpose of contraception is not a covered service.
Records show that you requested Mirena. Mirena is being requested to prevent conception. Medicare rules state that services requested to prevent conception are not covered as they do not meet Medicare's definition of "reasonable and necessary." We looked at the file and Medicare rules. The record shows that the reason for the request is for contraception. Based on this information, we decided that Medicare rules for coverage of the Mirena IUD have not been met. Therefore, we decided that the Plan does not have to pre-approve the Mirena IUD.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212 25) provided on December 9, 2019. 
 
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does to support that the significant, separately identifiable evaluation and management service (modifier -25) was rendered. 
 
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 case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the office visit. Our reviewer says that CPT code 99212 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted does not support that a separately identifiable service was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99212 25) provided on December 9, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a plastic surgery referral to the physician.
You asked the Plan to pre-approve these services. You say that your surgery was not done properly. The Plan denied your request. The Plan says that the referral is not 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 these services. Our reviewer says that the referral is medically necessary. Our physician reviewer found the records show that you underwent a previous vaginoplasty procedure approximately 30 years ago and report ingrown hairs. You are having possible functional problems related to the prior surgery. An evaluation from a physician that specializes in vaginoplasty for transgender patients is consistent with the standard of care. Your condition requires expert analysis and further evaluation. The referral is therefore reasonable and medically 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a plastic surgery referral to the physician.
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95810).
You asked the Plan to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep. 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. 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 polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided sleep study 95810 (in addition to study 95811) is not medically reasonable and necessary. Study 95810 duplicates the diagnostic portion of the approved study 95811. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95810).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on November 5, 2019.
You asked the Plan to pay for the orthosis and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
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 orthosis and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthosis and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthosis and sleeve were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthosis and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1851) and suspension sleeve (L2397) provided to the enrollee on November 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (99239)
provided November 19, 2019.
You asked the Plan to pay for hospital discharge day management services. You say that the medical records
provided will show proof of medical necessity. The Plan denied your request. The Plan says there is
insufficient documentation to corroborate the services and confirm Medicare coverage has been met.
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 99239 is hospital discharge day management services,
duration time of of 31 minutes or more.
We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation does not
include a hospital discharge day management note with a recorded duration time of 31 minutes or more. Based
on this information, we decided that Medicare rules for coverage of hospital discharge day management
services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day
management services (99239) provided November 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Horizant 600mg ER tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered 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 Horizant 600mg ER 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic pulmonary function test provided on February 27, 2020.You asked the Plan to waive the copayment for the diagnostic pulmonary function test. You say that you were sent for this treatment by your doctor and you were not told there was a cost affiliated with the service. 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 $125 copayment for diagnostic procedures and tests at an in-network outpatient hospital. You have been asked to pay a $125 copayment for the diagnostic pulmonary function test. The diagnostic pulmonary function test 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 for the diagnostic pulmonary function test provided on February 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist visits provided on February 20, 2020 and February 21, 2020.You asked the Plan towaive the copayments forspecialist visits. You say that you were in the hospital and disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each specialist visit. The medical records show that you received specialist visits on February 20, 2020 and February 21, 2020 during an observation stay. Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $70. You have been asked to pay the total copayment amount of $70 for specialist visits. Specialist visits fall within the outpatient hospital services 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 copayments forspecialist visits provided on February 20, 2020 and February 21, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Sinusotomy provided on October 23, 2019. 
 
You asked the Plan to pay for the Sinusotomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed. 
 
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 31030 is Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps. 
 
We asked our coder 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 Sinusotomy. Our reviewer says that CPT code 31030 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps, therefore this service cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Sinusotomy have not been met. Therefore, we decided that the Plan does not have to pay for a Sinusotomy provided on October 23, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided by a provider that is not enrolled in Medicare from January 24, 2020 to January 31, 2020.You asked the Plan to pay forhome health services. You say that these services were not available in-network.The Plan denied your request. The Plan says services from providers that do not participate in Medicare are not covered.The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The record shows that the services at issue were provided by a provider that does not participate in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pay forhome health services provided by a provider that is not enrolled in Medicare from January 24, 2020 to January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 2, 2020 to January 23, 2020.
You asked the Plan to waive the copayment for the SNF stay. You say that you do not believe you should be responsible for the copayment. 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 $0 copayment. for each day for days 1-20 and a $178 copayment each day for days 21-100. You have been asked to pay a $178 copayment for the SNF stay. The SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. See chart below.
Dates of Service
Service
Copayment per Day
SNF Days
Number of Days
Member Liability
January 2, 2020 to January 21, 2020
SNF stay
$0
1-20
20
$0
January 22, 2020 to January 23, 2020
SNF stay
$178
21
1
$178
Total
$178
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 SNF stay provided from January 2, 2020 to January 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the observation stay provided from October 1, 2019 to October 4, 2019.
You asked the Plan to reduce the copayment for the observation stay. You say that the enrollee should only be responsible for the $90 copayment that he was charged. The Plan denied your request. The Plan says that they confirmed the additional charge of $78.08 was removed from the enrollee's bill and the enrollee has 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment per stay for outpatient observation stays. The enrollee has been asked to pay a $400 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" benefit category. The record shows that the enrollee received observation services.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to reduce the copayment for the observation stay provided from October 1, 2019 to October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 24,2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory tests. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has topay 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 forthe medical services provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac injections (27096).
You asked the Plan to pre-approve bilateral sacroiliac injections. 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. 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 bilateral sacroiliac injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you have not participated in a physical therapy program, an activity modification program, or an active rehabilitation/therapeutic exercise program. The requested sacroiliac joint injections in this case are not medically reasonable or 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 bilateral sacroiliac injections have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral sacroiliac injections (27096).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on January 3, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that the CT scan was never completed so
believe you should not be liable for the copayment. 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 $150
copayment for each Medicare-covered advanced radiology service.
You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows the CT scan
was completed and results were 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 copayment for the CT scan provided on January 3, 2020.