Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stem cell injections for knee arthritis.
You asked the Plan to pre-approve the stem cell injections. You say that the records show that this is a medically necessary treatment. The Plan denied your request. The Plan says the requested stem cell therapy (Q4206) is considered experimental and is non-covered at this time.
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 stem cell injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found mesenchymal stem-cell (MSC) therapy is considered experimental or investigational for all orthopedic applications, including use in repair or regeneration of musculoskeletal tissue. In clinical trials, placement of mesenchymal stem cells into the knee joint has proved an effective treatment for osteoarthritis, with no significant increases in adverse events. However, no MSC therapies have yet been cleared by the FDA for human clinical application to musculoskeletal diseases. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the stem cell injections have not been met. Therefore, we decided that the Plan does not have to pre-approve stem cell injections for knee arthritis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgical services provided
June 21, 2019.

You asked the Plan to waive the coinsurance for the outpatient surgical services. You say that you are
requesting the plan review the original claim as it was denied under utilization review and the hospital should
not be billing you for any portion of this claim. The Plan denied your request. The Plan says this claim was
processed and the correct coinsurance was applied per the Evidence of Coverage.

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 25%
coinsurance for each covered surgery or observation in an outpatient hospital.

You have been asked to pay $2404.81 for the outpatient surgical services. This amount is lower than the plan's
cost share of $2,902.84 ($11,611.36 x 25%). Therefore, you are responsible for the total copayment. Therefore,
the outpatient surgical services fall 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
coinsurance for the outpatient surgical services provided June 21, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Planhasto pre-approveBIS extracellular fluid analysis for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis is considered investigational for use in the diagnosis, surveillance, or treatment of patients with lymphedema.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the testing is medically reasonable and indicated. This testing has the ability to help manage a potentially severe complication of therapy. Lymphedema is a common debilitating complication of surgery and XRT for breast cancer.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 pre-approveBIS extracellular fluid analysis for the enrollee.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 to review. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 17, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary and conducted a face-to-face assessment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, medical records do not support a prior face-to-face examination with the ordering physician within 6 months of ordering the DME or an appropriate use of telehealth. The submitted consultation notes do not support that a physical examination was performed. The information submitted does not confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on April 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not havethe serviceslaboratory services (CPT 82306, 83036, 86141) provided to the enrollee on October 1, 2019.You asked the Planthe servicesthe services. You say that this should be no charge.The Plandenied your request. The Plansaysthe services are not payable by Medicare.The Plan must follow Medicare rules. Medicare rules say that vitamin assay panels are not covered. The lab services at issue inthis case were for a vitamin assay panel. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not havethe serviceslaboratory services (CPT 82306, 83036, 86141) provided to the enrollee on October 1, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveferumoxytol injection for the enrollee.You asked the Planto pre-approvethe injection. You say that this is mediclaly necessary.The Plandenied your request. The Plansaysthere is no documentation of symptoms of iron deficiency anemia.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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no mention of any significant anemia or specifically any documentation of iron deficiency anemia. The review has determined that the documentation does not support that the requested ferumoxytol injection is medically reasonable or necessary for the enrollee. The documentationdoes not support that the injection is safe and effective for the enrollee.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-approveferumoxytol injection for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea semi-electric hospital bed (E0295) and mattress (E0271).You asked the Plan topre-approvea semi-electric hospital bed (E0295) and mattress (E0271). You say that the requested semi-electric hospital bed and mattress are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested semi-electric hospital bed and mattress.The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or2. Requires attachments which can only be attached to a hospital bed; AND3. Requires frequent changes in body position and/or has an immediate need for a change in body position.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 semi-electric hospital bed (E0295) and mattress (E0271). Our reviewer says that the enrollee does not meet criteria for the requested semi-electric hospital bed and mattress. Our physician reviewer found a semi-electric hospital bed is not medically necessary per Medicare National Coverage Determinations Manual. The documentation does not clearly reveal that the enrollee's condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for an immediate or frequent change in body position or special attachments that cannot be fixed on an ordinary bed. The documentation does not indicate that the head of the bed does not need to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. The request for a semi-electric hospital bed is not medically necessary for this enrollee. The mattress is denied because it is a replacement mattress for a person who already has a hospital bed. As the hospital bed was not approved, the mattress cannot be approved.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 semi-electric hospital bed (E0295) and mattress (E0271) have not been met.Therefore, we decided that the Plan does not have to pre-approvea semi-electric hospital bed (E0295) and mattress (E0271).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy services provided from March 11, 2020, to April 30, 2020.You asked the Plan to pay forhome infusion therapy services. You say that the Plan should pay this claim.The Plan denied your request. The Plan says this procedure code is not valid 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.In this case, the CPT Code Manual definition of code S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy management have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy services provided from March 11, 2020, to April 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing.
You asked the Plan to pre-approve genetic testing. You say that the requested genetic testing is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested
genetic testing.
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 genetic testing. Our reviewer says that
the enrollee does not meet criteria for the requested genetic testing. Our physician reviewer found the enrollee
is with non-small cell lung cancer. First line therapy would include chemotherapy+keytruda, irrespective of
PDL1, or keytruda alone for PDL1+. MSH6 is needed for MSI testing. MSI also gets keytruda. At this time
MSH6 is not indicated.
We looked at this physician's review, the file, and Medicare rules. Medicare rules also say testing for the ASPA
is not a Medicare benefit and is a statutorily excluded test. Based on this information, we decided that Medicare
rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to
pre-approve genetic testing.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says the service is not covered unless as part of a clinical trial.
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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the MILD procedure is experimental. More research is needed to show safety and efficacy.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve a percutaneous laminotomy/laminectomy.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora colonoscopy provided, by an out-of-network (OON) provider.

You asked the Plan to pay fora colonoscopy. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network.

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 fora colonoscopy provided, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a vitamin assay panel received on January 29, 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 this is not a covered benefit.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that vitamin
assay panels are not covered.
The services at issue in this case are statutorily not covered by Medicare or the plan. 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 a vitamin assay panel received on January 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3. You say that the medication is 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 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 Gelsyn-3. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the enrollee has not trialed
viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires
these be trialed first. The documentation does not outline contraindications or reasons these medications were
not considered. Without the support of the documentation, Gelsyn-3 is not approved, as step criteria have not
been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gelsyn-3 (J7328).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on August 10, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 forthe medical services provided to the enrollee by an out-of-network provider on August 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid (27096) provided on June 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe injection services. You say that you are resubmitting the appeal with the medical records attached. Please review for payment.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.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 forinjection of contrast for radiologic evaluation associated with SI joint arthrography and/or therapeutic injection of an anesthetic/steroid (27096) provided on June 1, 2020 by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power scooter (CPT Code K0800).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the documentation provided does not verify the power scooter meets LCD criteria.
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 DME. Our physician reviewer found the records do indicate the patient has a mobility deficit that limits the member's ambulation beyond about 20 feet due to weakness and discomfort. Based on the medical records provided there is documentation that a walker or cane are inadequate for the member's needs. A manual wheelchair is unaddressed in the available records. Based on the medical records provided there is no documentation that the member can safely operate a power mobility device. 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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the power scooter (CPT Code K0800).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services provided by an out of network (OON) provider.

You asked the Plan to pay for outpatient services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 outpatient services provided by an out of network (OON) provider.