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

We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87511,
87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on March 18, 2020.

You asked the Plan to pay for laboratory services. You say that this should be covered at the in-network rate.
The Plan denied your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87511, 87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on March 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 day reader.

You asked the Plan to pre-approve the services. You say that you have been waiting for three weeks for this
request. The Plan denied your request. The Plan says you are not on multiple insulin injections that require
dose adjustment.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you do not meet the criteria of three or more insulin shots daily, with adjustments based on blood
glucose levels. There is no clear description of why your needs can't be met with a glucometer.

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 not been met. Therefore, we decided that the Plan does not
have to pre-approve a Freestyle Libre 14 day reader.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine venipuncture (36415) rendered by the out of network (OON) provider on October 23, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the routine venipuncture (36415) rendered by the out of network (OON) provider on October 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 10, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 

We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta Injection.

You asked the Plan to pre-approve Zilretta Injection, triamcinolone acetonide, preservative-free, extendedrelease,
microsphere formulation, 1 mg (J3304). You say that you want the enrollee to be treated with this drug.

The Plan denied your request. The Plan says the enrollee has not tried and had an intolerance of dexamethasone
injection, methylprednisolone injection and triamcinolone injection.

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 Zilretta Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg (J3304). Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the provided records do not sufficiently show that the patient had an adequate trial of each of the following with an inadequate response or intolerance: 1) dexamethasone injection; 2) methylprednisolone injection; and 3) triamcinolone injection. Zilretta is triamcinolone, a corticosteroid like the other medications listed above, and it would not be expected that this medication would be more effective or safer that the above alternatives. 

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, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg (J3304) have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta Injection.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided July 16, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the services billed.

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 97530 is not supported in the medical record. Specifically, the services were provided
in the home setting. There is a more appropriate CPT code to describe the services in this setting (G0158).
Based on this information, we decided that Medicare rules for coverage of the therapy services have not been
met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided July 16,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and Part B drugs you
received from February 2, 2021, to February 23, 2021.

You asked the Plan to waive the cost share. The Plan denied your request. The Plan says you are responsible
for the cost share.

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 Medicare Part B covered drugs. Your contract also says that you must pay a $45 copayment for
specialist services.

Review of the file shows that you had a specialist visit and received Part B drugs from February 2, 2021, to February 23, 2021. You have been asked to pay a $45 copayment for the specialist visit and a 20% coinsurance for the Part B drugs. 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 cost share for the office visit and Part B drugs you received from February 2, 2021, to February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for endodontic therapy. We decided that the Plan does not have to pay for a
cone beam CT scan (D0364).

You asked the Plan to pay for endodontic therapy and a cone beam CT scan and to waive the cost sharing for a
limited oral evaluation. You say that you were told by a representative of the Plan that the services at issue are
a covered benefit. The Plan says that the services at issue are not covered under the Plan.

We decided that the Plan has to pay for endodontic therapy (D3330) and to waive the cost sharing for a
limited oral evaluation (D0140).

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has not documented that endodontic therapy is not part of
your particular dental benefit. Furthermore, the Plan has not documented that the cost of a limited oral
evaluation on June 4, 2020, caused you to reach the yearly maximum for the dental benefit. The Plan did not
respond to a request for this information. Therefore, we decided that the Plan has to pay for endodontic therapy
(D3330) and to waive the cost sharing for a limited oral evaluation (D0140).

We also decided that the Plan does not have to pay for a cone beam CT scan (D0364).
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 service coded D0364 is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a cone beam CT
scan (D0364).

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.

Your complaint about receiving erroneous or incomplete information about your dental benefit from a
representative of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance
that must be answered by the Plan. Medicare does not permit us to make a decision about these types of
complaints.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Eylea (J0178).

You asked the Plan to pre-approve Eylea. You say that the enrollee is unable to fulfill step therapy
requirements due to a shortage of the step therapy drug Avastin. The Plan denied your request. The Plan says
that step therapy rules have 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 Eylea. Our reviewer says that the
requested treatment is medically necessary. Our physician reviewer found that the Plan requires a trial of drug
Avastin before they will approve the requested drug. The enrollee has not tried and failed the required drug.
The major compounder of Avastin in the United States has recently shut down distribution of the required step
therapy drug. Consequently, there is a shortage of Avastin. You have documented that, as a result, the enrollee
was unable to start treatment with Avastin and instead was started on Eylea. Step therapy may only be applied
to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected
medication.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Eylea have been met. Therefore, we decided that the Plan has to pre-approve
treatment with Eylea (J0178).

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the head (70450) provided March 18, 2021.

You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied your request. The Plan says the CPT code billed is not separately payable.

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, we have confirmed that code 70450 has a Column I / Column II relationship with code 704926 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for computed tomography (CT) of the head (70450) provided March 18, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve non-emergency ambulance transportation from home to a dialysis center.

You asked the Plan to pre-approve the non-emergency ambulance transportation from home to a dialysis center. You say that the enrollee requires dialysis 2 times a week. You say he is non-ambulatory and unable to stand or walk and he will continue to need ambulance transport to and from the dialysis center for treatments. The Plan denied your request. The Plan says that the clinical presentation does not indicate bed confinement where the individual can't be moved by wheelchair and must be moved by stretcher. The clinical indicates transportation other than an ambulance (e.g., private car, wheelchair van, etc.) could be utilized without endangering the individual's health, whether or not such other transportation is actually available.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. 

The Plan has not provided medical records to substantiate the denial for ambulance transportation from home to a dialysis center. Therefore, we decided that the Plan has to pre-approve non-emergency ambulance transportation from home to dialysis center.

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 first intraoral periapical x-ray and additional intraoral
periapical x-ray provided on February 25, 2021.

You asked the Plan to pay for the intraoral periapical x-rays. You say that the reason they did not do a full
mouth, bitewing, or panoramic x-ray is because you only have 9 lower teeth in the front of your mouth. You
also say that you believe this claim should be paid by the Plan. The Plan denied your request. The Plan says
periapical x-rays are not covered under your plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first
intraoral periapical x-ray and additional intraoral periapical x-ray provided on February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on June 24, 2020.
You asked the Plan to pay for the drug testing. You say that the records support this service. The Plan denied your request. The Plan says the claim was not billed with an appropriate POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly.
We looked at the file and Medicare rules. The documentation shows that the sample was taken in the office setting, and not directly by the laboratory. As such, POS code 81 is not supported. 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 for the definitive drug testing provided on June 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is a Medicare-covered service. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show that it is safe and effective. 

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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on December 22, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network (OON) provider on December 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.

You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have 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 Hyalgan. Our reviewer says that the requirements for coverage of Hyalgan have not been met. Our physician reviewer found the Plan requires a trial of Synvisc and Gelsyn-3 before they will approve the requested drug. The records do not indicate that the enrollee has tried and failed the required drugs or that these drugs would not be appropriate 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract surgery (66984) provided on
February 23, 2021, to March 16, 2021.
You asked the Plan to waive the copayment for cataract surgery. You say that you are on a fixed income that
does not provide you with money to pay this bill. The Plan denied your request. The Plan says the copayment
you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $335
copayment for each outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers.
You have been asked to pay a $335 copayment for each cataract surgery. The records show you had two
cataract surgeries. Your total cost share is $670 ($335 x 2 cataract surgeries = $670). The EOC confirms $335
is the required copayment for each service. Cataract surgery falls within the outpatient surgery, including
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means
that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for cataract surgery (66984) provided on February 23, 2021, to March
16, 2021.