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

We decided that the Plan does not have to pay for the COVID-19 testing you were provided.

You asked the Plan to pay for the testing. You say that this is required for your employment.The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that the routine physical checkup exclusion applies to examinations required by third parties such as insurance companies, business establishments, or Government agencies.


We looked at the file and Medicare rules. The requested COVID-19 testing was required by a third party for employment purposes. This is not a covered benefit under Medicare or your plan. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore,we decided that the Plan does not have to pay for the COVID-19 testing you were provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 metastatic lobular breast cancer diagnosed in 2016. She has ER/PR positive progressive disease, despite several prior lines of therapy. She was started on pembrolizumab in 2018 on compassionate basis with good response. Pembrolizumab is FDA approved for the treatment of locally recurrent unresectable or metastatic triple-negative breast cancer in patients whose tumors express PD-L1 (combined positive score [CPS] greater than or equal to 10) as determined by an approved test. There is no information regarding the enrollee's PD-L1 status or MSI status, and to date the medical literature does not support use in patients with hormone positive cancers. The service is 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 Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) as defined by codes L3670 RTKX, L1833 RTKX, L2397 RTKX and L0650 provided to the enrollee on June 22, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the record does not contain a valid proof of delivery to support medical necessity for the supplies provided in this case.
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 proof of delivery to support medical necessity for the supplies provided in this case. There is no itemized billing/shipping invoice to verify the services billed. 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 the durable medical equipment (DME) as defined by codes L3670 RTKX, L1833 RTKX, L2397 RTKX and L0650 provided to the enrollee on June 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by an out-of-network provider on August 3, 2020.
You asked the Plan to waive the copayment for an outpatient surgery. You say that you only paid $200 before.
The Plan denied your request. The Plan says the correct coinsurance 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 45%
coinsurance for outpatient surgery/out-of-network.
You have been asked to pay a 45% coinsurance of the allowed amount for an outpatient surgery. The total
allowed amount is $13,817.09. The total amount you are being asked to pay is $6,217.69 ($13,817.09 x 45% =
$6,217.69). An outpatient surgery falls within the outpatient surgery/out-of-network 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 outpatient surgery provided by an out-of-network
provider on August 3, 2020.
Appeal type: Testing
Decision: Unfavorable

e decided that the Plan does not have to waive the copayment formyocardial perfusion imaging provided on July 31, 2020.You asked the Plan to waive the copayment formyocardial perfusion imaging. You say that you cannot afford 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 $200 copayment for each diagnostic radiology service. You have been asked to pay a $200 copayment for myocardial perfusion imaging. Myocardial perfusion imaging 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 formyocardial perfusion imaging provided on July 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the vision care services you received on August 10, 2020.
You asked the Plan to waive the copayments for the vision care services. You say that you would like the Plan to pay its share for these services. The Plan denied your request. The Plan says this copayment was charged correctly and your claim has been paid minus this applicable copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for vision care services. You have been asked to pay a $50 copayment for the vision care 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 copayments for the vision care services you received on August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 24, 2020.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you needed the portable oxygen concentrator so you could recharge it while driving or traveling. The Plan denied your request. The Plan says Medicare and the Plan only cover the rental of oxygen devices from approved in-network suppliers.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on May 26, 2020.
You asked the Plan to pay for the services. You say that these services were paid for before. The Plan denied your request. The Plan says this provided has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services you received on May 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the oxygen concentrator purchased on March 5, 2020.
You asked the Plan to reimburse you for the oxygen concentrator. You say that you did not realize a medical prescription had to be approved. The Plan denied your request. The Plan says per Medicare guidelines payment is not made for purchases of oxygen and oxygen equipment.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the oxygen concentrator purchased on March 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on January 8, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on January 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen (74150).You asked the Plan to pre-approvea CT scan of the abdomen. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.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 a CT scan of the abdomen. Our reviewer says that the services are not medically necessary. Our physician reviewer found theoriginal authorization for the approved scan, CT of the abdomen was inadvertently not cancelled following the change in the order by the ordering physician to the subsequently ordered and performed CT of the abdomen and pelvis of October 29, 2020. You report continued abdominal pain but has not been reevaluated by the attending physician. Absent clinical re-evaluation and the attending physician's opinion that a repeat CT scan is indicated the medical necessity of another CT of the abdomen has not been established.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the abdomen have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the abdomen (74150).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora neuromuscular stimulator (HCPCS E0745) provided to the enrollee.

You asked the Plan to pay for the stimulator. You say that this should be paid for.The Plan denied your request. The Plan says codes classified as category CR have to be submitted with the correct DME modifier.

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 HCPCS code E0745 is "Neuromuscular stimulator, electronic shockunit.

"We asked our coding 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 stimulator. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found that the documentation submitted was reviewedand does not meet criteria. DME was billed with an appropriate modifier. Per HCPCS guidelines, E0745 DME Modifier: RR should be used. Per Medicare guidelines A TENS unit must be rented for the first month. The Medicare rental modifier is "RR". When the item is purchased, utilize the purchase modifier for new equipment "NU"  

 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 stimulator have not been met.Therefore, we decided that the Plan does not have to pay fora neuromuscular stimulator (HCPCS E0745) provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 24, 2020, to January 29, 2020.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says inpatient admission was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department January 24, 2020, with mild right shoulder and right hip pain after a mechanical slip and fall. She denied any head injury, headache, ankle pain, knee pain, rib pain, collar bone pain or any other complaints. Diagnostic testing was negative for fracture.
She received a physical therapy evaluation the day of admission, and was recommended rehab at a skilled nursing facility. The was a delayed discharge due to placement issues. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 24, 2020, to January 29, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says imaging may be supported if the cause of the symptoms is unclear after a doctor assessment.
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 the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the records do not show evidence of alteration of adult daily living activities and no differential including FTD to justify PET imaging of the brain. CMS rules do not allow PET imaging of the brain unless there is a differential between Alzheimer's disease vs. FTD. All other neurodegenerative diseases are not considered indications for the scan including Lewy body dementia etc. While the enrollee has an abnormal MMSE of 25/30 there are no symptoms to suggest FTD in order to justify the requested PET scan. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there is no evidence that the enrollee requires services that are not currently available.
As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no
advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such
time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for
any ongoing long term care (LTC) needs.
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99215) to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to
provide these services. Therefore, coverage criteria has not been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office visit (99215) to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows healthplans 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 the medication is not medically necessary. Our physician reviewer found the enrollee has not tried zoledronic acid according to the provided documentation. Also, zoledronic would not be expected to be less effective or cause more adverse effects for the patient, based on the history and other documentation. Although the patient has GERD, zoledronic acid is an infused medication which does not aggravate GERD as opposed to oral bisphosphonate therapy options. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded 80307 and G0482 provided on February 5, 2020.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. The submitted Laboratory Requisition indicates that a toxicology profile 11113 Panel wasrequested. Thesubmitted documentation does not itemize what tests are included in this panel. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing coded 80307 and G0482 provided on February 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for practitioner services provided to the enrollee on June 3, 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 the provider is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care. The services at issue were provided in a non-urgent,
non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that
the Plan does not have to pay for practitioner services provided to the enrollee on June 3, 2020.