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

We decided that the Plan does not have to pre-approve a genetic testing/general gene panel for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says if there is no documentation that the evaluation/testing was in relation to specific
symptoms or treatment, the test is considered a screening service, and denied as not covered by Medicare.
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 testing. Our reviewer says that the
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is limited documentation provided - only a PA form. There is no evidence to support that the
provided service is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee'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 testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve a genetic testing/general gene panel for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a colonoscopy provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a colonoscopy. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 to pay 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 for a colonoscopy provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive evaluation provided on November 22, 2019.
You asked the Plan to waive the copayment for the comprehensive evaluation. You say that this was your annual gynecologist exam. You say that you thought this was fully covered. The Plan denied your request. The Plan says the copayment 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 $45 office visit copayment if services are provided by a specialist. You have been asked to pay a $45 copayment for the comprehensive evaluation. The comprehensive evaluation falls within the "Physician/Practitioner services, including doctor's office visits" 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 comprehensive evaluation provided on November 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Travatan Z for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is 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 pre-approve Travatan Z for the enrollee.
Benefits for this drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sterilization (58661).
You asked the Plan to pre-approve sterilization. You say that the enrollee has multiple co-morbidities. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that elective sterilization and sterilization that is performed because a physician believes another pregnancy would endanger the overall general health of the woman are not considered to be reasonable and necessary and are not covered. We looked at the file and Medicare rules. The record indicates the sterilization at issue is elective and has been requested due to the risk pregnancy poses to the health of the enrollee. This is not considered medically necessary under Medicare rules. Based on this information, we decided that Medicare rules for coverage of sterilization have not been met. Therefore, we decided that the Plan does not have to pre-approve sterilization (58661).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services and lab work provided on June 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services and lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was 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 to pay 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 for physician services and lab work provided on June 14, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from October 16, 2019 to October 23, 2019.
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 this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the fee schedule. This means that this code is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (HCPCS S9328) provided to the enrollee from October 16, 2019 to October 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Single Photon Emission Computed Tomography (SPECT)
imaging (78452) provided June 6, 2019.
You asked the Plan to pay for the SPECT imaging. You say that the SPECT imaging was medically necessary.
The Plan denied your request. The Plan says rules 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 pay for the SPECT imaging. Our reviewer says that
the services at issue were not medically necessary. Our physician reviewer found submitted documentation
includes the result of the study. There are no other medical records included for review. Without the
documentation, medical necessity cannot be 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 the SPECT imaging have not been met. Therefore, we decided that the Plan
does not have to pay for Single Photon Emission Computed Tomography (SPECT) imaging (78452) provided
June 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 13, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you received a $20 charge for a wellness visit. The Plan denied your request. The Plan says the copayment 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 copayment for each primary care doctor visit for Medicare-covered benefits.
You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that asthma and anxiety were addressed during the office visit. 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 office visit provided on November 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on December 13, 2019.
You asked the Plan to waive the copayment for the breast ultrasound. You say that this is considered preventive. You say that you shouldn't be charged extra. The Plan denied your request. The Plan says the copayment 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 $40 copayment for each basic imaging service. You have been asked to pay a $40 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The breast ultrasound is considered diagnostic imaging. 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 breast ultrasound provided on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips.
You asked the Plan to provide additional routine transportation trips. You say that you have appointments remaining for this year. The Plan denied your request. The Plan says that the 51st trip and beyond is not a covered benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of fifty (50) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan does not have to cover routine transportation of the benefit maximum of 50 trips. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation services provided on October 8, 2019.
You asked the Plan to pay for the transportation services. You say that it was medically necessary for the
enrollee to be transported, as they were not fit to use any other form of transportation. You also say that you are
not an ambulance, as an ambulance would be far too uncomfortable for long distance transports. The Plan
denied your request. The Plan says the transportation was not reasonable and necessary
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. Ambulance services are covered when transport is to the
nearest facility to obtain necessary diagnostic and/or therapeutic services. Medicare does not cover transport in
a vehicle that is not an ambulance. The Plan follows the same rule.
The services you have asked the Plan to pay for are for transport services from the facility in Brooksville, Florida to the facility in Somerset, New Jersey.
This was not the nearest appropriate facility. In addition, you state that the vehicle used for the transportation
services in dispute was not an ambulance. Therefore, we decided that the Plan does not have to pay for
transportation services provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee uses the
non-preferred brand of meter and test strips. The Plan denied your request. The Plan says there is no medical
reason documented that the enrollee is medically unable to use the Plan preferred test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is
necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for
coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does
not have to pre-approve OneTouch Verio test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the assay of carbamazepine rendered to the enrollee on August 21, 2019.
You asked the Plan to pay for these 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 laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the assay of carbamazepine rendered to the enrollee on August 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ZILRETTA (triamcinolone acetonide) injection 1mg (J3304).
You asked the Plan to pre-approve ZILRETTA injection. You say that you have diabetes and are concerned about having appropriate treatment that would not interact badly with your condition. Your doctor prescribed it due to knee pain and in order to avoid surgery. The Plan denied your request. The Plan says it is not reasonable and necessary to use this specific triamcinolone preparation ZILRETTA. The plan agreed that a steroid injection is medically necessary and has instead approved Triamcinolone 40mg/ml injection.
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 ZILRETTA injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee has a diagnosis of osteoarthritis of the knee. The enrollee was treated with ZILRETTA injection previously with good effect several months prior. A subsequent request for a similar injection was submitted. Review of compendia note the safety and efficacy of repeat injection with ZILRETTA is not supported. Medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ZILRETTA injection have not been met. Therefore, we decided that the Plan does not have to pre-approve ZILRETTA (triamcinolone acetonide) injection 1mg (J3304).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient consultation (99254) provided on August 22, 2019.
You asked the Plan to pay for the inpatient consultation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99254 has a status indicator of I which is invalid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99254 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code 99254 has a status code of I. This means that CPT code 99254 is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation have not been met. Therefore, we decided that the Plan does not have to pay for inpatient consultation (99254) provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 20, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 pay 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services provided on August 21, 2018.
You asked the Plan to pay for the vision services. You say that you would like the claim to be reprocessed and paid. The Plan denied your request. The Plan says that the claim was filed outside the 12 month timeframe allowed for claims submission.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the vision services was not filed until December 5, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the vision services provided on August 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 pay 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 for the medical services provided on February 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an electroencephalogram (EEG) (95955), nerve conduction studies (95910), and needle electromyography (95885) provided on August 8, 2019.
You asked the Plan to pay for an EEG, nerve conduction studies, and needle electromyography. You say that these codes are eligible for payment. The Plan denied your request. The Plan says these codes are 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 code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery), 95910 is nerve conduction studies; 7-8 studies, and 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). 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 an EEG, nerve conduction studies, and needle electromyography. Our reviewer says that these codes are not supported. Our physician reviewer found there is no evidence that EEG monitoring during carotid surgery was performed. There is also no evidence that nerve conduction studies were performed. As nerve conduction studies were not performed, 95910 cannot be billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an EEG, nerve conduction studies, and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for an electroencephalogram (EEG) (95955), nerve conduction studies (95910), and needle electromyography (95885) provided on August 8, 2019.