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

We decided that the Plan does not have to pre-approvedrug testing (G0483) provided on December 2, 2019.You asked the Plan to pre-approvedrug testing. You say that this is supported in the records.The Plan denied your request. The Plan says this was billed with an incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).We looked at the file and Medicare rules. The service at issue was billed with POS code 81 for an independent laboratory, but the records indicate that the specimen was collected in an office visit. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met.Therefore, we decided that the Plan does not have to pre-approvedrug testing (G0483) provided on December 2, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe bone replacement graft for ridge preservation (D7953) provided on July 10, 2020.You asked the Plan to pay forthe bone replacement graft. You say that the surgeon decided that you needed a bone graft to prepare the area for an implant.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe bone replacement graft for ridge preservation (D7953) provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that your medical needs are being met in the current acute setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term acute care hospitals are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. You are receiving acute hospital care and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran x-ray (73630) provided September 2, 2020.You asked the Plan to waive the copayment forthe x-ray. You say that the copayment should be waived.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 $30 copayment for X-rays. You have been asked to pay a $30 copayment for the x-ray. 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 foran x-ray (73630) provided September 2, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveAranesp (albumin free) 500MCG/ML solution prefilled syringe (CPT Code J0881).You asked the Plan to pre-approvethe medication. You say that the medication is necessary.The Plan denied your request. The Plan says that the Medicare criteria have not been 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 the medication. Our physician reviewer found given the nature of anemia and the inability to give transfusions due to the patient being a Jehovah's Witness the Aranesp is medically reasonable and indicated. Transfusion isnot an option in the management of the enrollee's anemia.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 medication have been met.Therefore, we decided that the Plan has to pre-approveAranesp (albumin free) 500MCG/ML solution prefilled syringe (CPT Code J0881).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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forblood bank physician services (86077) provided on September 14, 2020.You asked the Plan to pay forthe blood bank physician services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says CPT 86077 has an MUE value of 1 but 2 units were billed.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 86077 is 1. You billed2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the blood bank physician services have not been met.Therefore, we decided that the Plan does not have to pay forblood bank physician services (86077) provided on September 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe blepharoplasty.You asked the Plan to pre-approvethe blepharoplasty. You say that you would like reconsideration because this service is medically necessary.The Plan denied your request. The Plan says the visual field loss in the member's left eye is no significant.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 blepharoplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no visually significantjustification for blepharoplasty or brow ptosis repair.  The member's superior visual field in both eyes did not improve 30 percent with lid/brow taping.  In addition, there were no photos provided to objectively evaluate member's condition.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 blepharoplasty have not been met.Therefore, we decided that the Plan does not have to pre-approvethe blepharoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea Botox injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysstep therapy criteria is not met.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 drug is not medically reasonable or necessary.Our physician reviewer found this drug is only available after failed step therapy of the approved drugs. Step therapy guidelines/requirements were not met 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 the injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea Botox injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.You asked the Plan to pre-approveIRF care. You say that an intense rehab program will provide an opportunity for the enrollee to become independent with his prosthesis in a safe environment and in a timely manner.The Plan denied your request. The Plan says that it is not reasonable to expect that the enrollee needs, or can fully benefit from the intensity of services of an IRF.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient is living at home with complaints of weakness and trouble ambulating using prosthetic leg. The enrollee's medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora dental exam (D0160) provided August 14, 2020.You asked the Plan to pay forthe dental exam. You say that this service was medically necessary and should be covered.The Plan denied your request. The Plan says this type of dental exam is not covered under your benefit.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay fora dental exam (D0160) provided August 14, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fordental services (D0272, D0120, D0220, D1110) provided September 17, 2020.You asked the Plan to pay forthe dental services. You say that the services should be covered.The Plan denied your request. The Plan says the benefit was exhausted.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, the plan's benefit is limited to $300. The out-of-network provider charged more than is coveredby the plan.Therefore, we decided that the Plan does not have to pay fordental services (D0272, D0120, D0220, D1110) provided September 17, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forpacemaker surgery provided on October 9, 2020.You asked the Plan to waive the copayment foroutpatient surgery. You say that this was to correct the initial procedure, so you should not be liable for a second copayment.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $75 copayment for outpatient surgery. You have been asked to pay $75 copayment for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 forpacemaker surgery provided on October 9, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formassage therapy and electrical stimulation provided from January 15, 2020, to February 10, 2020.You asked the Plan to pay formassage therapy (97124) and electrical stimulation (G0283). You say that the Plan should pay this claim.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay formassage therapy and electrical stimulation provided from January 15, 2020, to February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Planhasto pay forknee orthoses (HCPCS L1833 and L2397) provided to the enrollee on August 25, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthata review of the claim history was conducted and showed no claim for the ordering physician.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 the denied codes is:HCPCS L1833:Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelfHCPCS L2397:Addition to lower extremity orthosis, suspension sleeveWe 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 services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found the documentation included an itemized delivery ticket with tracking, a physician's visit with a patient and physician order.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 services have been met.Therefore, we decided that the Planhas to pay forknee orthoses (HCPCS L1833 and L2397) provided to the enrollee on August 25, 2020.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic colonoscopy provided on August 22, 2020.You asked the Plan to waive the copayment forthe diagnostic colonoscopy. You say that you were unaware that this procedure was considered a surgery. 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 $400 copayment for each Medicare-covered outpatient surgery at an in-network outpatient hospital. You have been asked to pay a $400 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the diagnostic colonoscopy is considered a surgical procedure.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 diagnostic colonoscopy provided on August 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe IV therapy and Part B drugs provided on September 9, 2020 and September 16, 2020.You asked the Plan to waive the cost share forthe IV therapy and Part B drugs. You say that you feel you should not beresponsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received IV therapy and Part B drugs on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your 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). Your contract with the Plan clearly says that you must pay a $250 copayment per visit for Medicare-covered Surgical, IV Therapy and Blood Transfusion services and a 20% coinsurance for Medicare-covered Part B drugs. We looked at the file, the Plan's contract and Medicare rules. The fileshows that you received IV therapy and Part B drugs on September 9, 2020 and September 16, 2020. You have been asked to pay a $250 copayment for the IV therapy for each date of service, totaling $500. You have also been asked to pay a 20% coinsurance for the Part B drugs for each date of service, totaling $300.70. The IV therapy and Part B drugs fall within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct amounts 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 cost share forthe IV therapy and Part B drugs provided on September 9, 2020 and September 16, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Invitae Pancreatic Cancer Panel provided on December 24, 2019.You asked the Plan to pay forthe testing services. You say that you would like reconsideration because this testing provides validated clinical utility in clarifying disease risk, guiding clinical decision making, and assisting both the physician and patient in making medical management decisions.The Plan denied your request. The Plan says this service has not been billed correctly.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, the testing services, 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 forthe Invitae Pancreatic Cancer Panel provided on December 24, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora cardiovascular risk assessment panel provided to the enrollee on March 2, 2020.You asked the Planto pay forthe panel. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.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 requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the cardiovascular risk assessment panel provided on 3/2/20 was medically reasonable and necessary for the enrollee in this case. There are no clinical records available for review.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 Plandoes not haveto pay fora cardiovascular risk assessment panel provided to the enrollee on March 2, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Auricular Peripheral Nerve Stimulation device for the enrollee.You asked the Plan to pre-approvethese services. You say that the enrollee has a long history of chronic pain syndrome, acute low back pain, knee pain, and shoulder pain.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that the service for auricular peripheral nerve stimulation will be denied as non-covered.We looked at 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-approveanAuricular Peripheral Nerve Stimulation device for the enrollee.