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

We decided that the Plan does not have to pre-approve Xolair.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has asthma and a dust mite
allergy. Her IgE level is documented as 15.6 on March 17, 2021. The IgE level needs to be 30 or greater for
Xolair to be approved. The enrollee has been tested twice, and the levels were 15.6 and 18. The Xolair is
therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve Xolair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic procedures provided on February 21, 2020.
You asked the Plan to pay for therapeutic procedures (97110). You say that the Plan should pay this claim. The Plan denied your request. The Plan says G0151 is the appropriate code for the billed service.
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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the claim was submitted with place of service Home, therefore the code G0151 is the correct code. Based on this information, we
decided that Medicare rules for coverage of therapeutic procedures (97110) have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic procedures provided on February 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided by a participating provider on February 16, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that you do not feel like you should have to pay for this. 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 $40 copayment for outpatient diagnostic tests/in-network/x-rays/specialist's office. You have been asked to pay $34.35, which is less than your copayment amount of $40 for an x-ray. Since an x-ray was provided, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic
tests/in-network/x-rays/specialist's office 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 an x-ray provided by a participating provider on February 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral
branches.
You asked the Plan to pre-approve RFA of the lateral sacral branches. You say that the requested service is
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have 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 RFA of the lateral sacral branches. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found this service is considered experimental/investigational due to the wide
variation in efficacy reported in the peer reviewed literature. Therefore, the request is deemed 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 RFA of the lateral sacral branches have not been met. Therefore, we decided
that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the lateral sacral branches.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the cervical spine.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of cervicalgia associated with spinal stenosis and myelopathy. He underwent cervical fusion in October of 2020 and a follow up CT scan in December of 2020 is reported to "look good." There are no further records to support the need for a second CT scan. The services are not 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 computed tomography (CT) scan of the cervical spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for rebase lower partial denture (D5721) provided on January 28, 2021.
You asked the Plan to pay for rebase lower partial denture. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered 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 for rebase lower partial denture (D5721) provided on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair provided on January 15, 2020.
You asked the Plan to pay for the wheelchair. You say that the power wheelchair was prescribed by the enrollee's physician. The Plan denied your request. The Plan says this is not a covered benefit without an appropriate evaluation by the enrollee's provider.
The Plan must follow Medicare rules. Medicare rules say that power mobility devices are only covered under certain medical indications. We looked at the file and Medicare rules. The records provided do not indicate the enrollee's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the wheelchair. 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 for the power wheelchair provided on January 15, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on March 11, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says per the Medicare database, the enrollee was in hospice status from March 11, 2020 through March 13, 2020. In accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on March 11, 2020. Per the regulations above, the member's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. It is the provider's responsibility to verify the member's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided by a participating provider on February 12, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a post-op appointment. You say that you should not have to pay for this. 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 $40 copayment for physician/practitioner services/in-network/specialist's office. You have been asked to pay a $40 copayment for a specialist visit. Post-operative appointments are still subject to a copayment; therefore, the correct copayment has bene applied. A specialist visit falls within the physician/practitioner services/in-network/specialist's office 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 a specialist visit provided by a participating provider on February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0425, A0428) provided on January 21, 2021.
You asked the Plan to pay for the non-emergent ambulance services. You say that the ambulance services were necessary due to the enrollee's COVID status. The Plan denied your request. The Plan says non-emergent ambulance transportation was not medically necessary in this case.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance services. Our reviewer says that the criteria for non-emergent ambulance transportation are not met. Our physician reviewer found this enrollee presented to the emergency room and tested positive for COVID-19. The enrollee could not go home in a cab due to their COVID status. There were no other complaints. The enrollee was able to stand on their own and walk around. The documentation does not support that all other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on the date in question. The documentation does not support that the ambulance transport was medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation services (A0425, A0428) provided on January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 15, 2021, to January 16, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were not given the option to self-administer the medications. You also say that you were not allowed to bring your own drugs with you. The Plan denied your request. The Plan says self-administered drugs are not covered under Part B.
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 pay for the self-administered drugs provided from January 15, 2021, to January 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you have chronic obstructive pulmonary disease (COPD) with chronic respiratory failure. A blood gas study from one year ago demonstrated oxygen levels appropriate for bilevel positive airway pressure (BiPAP) therapy. The records do not support the use of a ventilator over a BiPAP device. The ventilator is therefore not 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 home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurances for the cataract surgeries provided from January 7, 2021 to January 21, 2021.
You asked the Plan to waive the coinsurances for the surgeries. You say that you were not informed of your payment obligation. The Plan denied your request. The Plan says that the coinsurance applied correctly.
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 facility visit.
You have been asked to pay a 10% coinsurance for the surgeries. The surgeries fall within the Medicare-covered outpatient hospital facility visit 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 coinsurances for the cataract surgeries provided from January 7, 2021 to January 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a therapeutic CGM device (K0554) with sensors (K0553) provided on January 14, 2021.
You asked the Plan to pay for a CGM with sensors. You say that the requested items are a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the document submitted as proof of delivery indicates a need for a signature. The document is not signed. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a therapeutic CGM device (K0554) with sensors (K0553) provided on January 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of home health skilled nursing care
after May 5, 2021.
You asked the Plan to pre-approve home health skilled nursing care. You say that this request is medically
necessary. The Plan denied your request. The Plan says home health skilled nursing care is no longer medically
necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health skilled nursing care. Our
reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer
found based on the medical records provided there is no documentation that skilled nursing services are
required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or
to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration.
Records do not document any wounds, intravenous treatment, acute change in condition or medication changes
that would necessitate skilled nursing care; the enrollee is on oral medications for her conditions. Oral
medication administration is not a skilled nursing service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health skilled nursing care have not been met. Therefore, we decided that
the Plan does not have to pre-approve the continuation of home health skilled nursing care after May 5, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services (CPT 87086, CPT 87801) provided to the enrollee on November 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that this coding is not supported.
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: CPT 87086: Culture, bacterial; quantitative colony count, urine CPT 87801: Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms 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 services. Our reviewers says that the services at issue in this case were supported by the medical records. Our physician reviewer found the review indicates that the records supported the above denied codes. There are lab results in the case file confirming the denied tests were rendered 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 services have been met. Therefore, we decided that the Plan has to pay for laboratory services (CPT 87086, CPT 87801) provided to the enrollee on November 30, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) received February 1, 2021 received from the out-of-network provider.
You asked the Plan to pay for the intraoral radiographic image. You say that you have seen this dentist for years and would like the claim paid. The Plan denied your request. The Plan says this provider is not part of the Plan's dental provider network.
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. There is no coverage for services received outside of the Plan's dental
provider network. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) received February 1, 2021 received from the out-of-network provider.