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

We decided that the Plan does not have to pre-approve breast cancer genetic testing (BRCA).
You asked the Plan to pre-approve the BRCA testing. You say that your youngest sister was diagnosed with metastatic stage 4 breast cancer. You say that you were told to get the requested test because your sister has the gene. You say that there is no cure for this particular cancer. You say that you would like to know if you have the gene in order to prepare for what's ahead. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that BRCA1/BRCA2 genetic testing is not covered for testing of individuals with no personal history of cancer.
We looked at the file and Medicare rules. The records show that you are requesting the testing in dispute for screening purposes and that you have no personal history of cancer. Based on this information, we decided that Medicare rules for coverage of the BRCA testing have not been met. Therefore, we decided that the Plan does not have to pre-approve breast cancer genetic testing (BRCA).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on February 26, 2021.
You asked the Plan to pay for psychotherapy, 30 minutes with patient (90832). You say that your physician
provided medically necessary services to the member in good faith. The Plan denied your request. The Plan
says there was no documented contact with the attending /primary care physician.
The Plan must follow Medicare rules. Medicare rules say that there must attempt to consult the attending or
primary care physician about the services furnished and document the consent or declination date to
consultations, and the date of consultations in the patient's medical record.
We looked at the file and Medicare rules. There is no documentation of consent/declination or consultation
with the enrollee's attending or primary care physician. Based on this information, we decided that Medicare
rules for coverage of psychotherapy, 30 minutes with patient (90832) have not been met. Therefore, we decided
that the Plan does not have to pay for psychotherapy provided on February 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76700) provided on May 13, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an ultrasound on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $125 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an ultrasound on May 13, 2021. You have been asked to pay a $125 copayment for the ultrasound. The ultrasound falls within the Outpatient diagnostic tests 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 ultrasound (76700) provided on May 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the continued SNF stay provided from May 19, 2021, to June 17, 2021.

You asked the Plan to pay for the continued SNF stay. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 continued SNF stay. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

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 continued SNF stay have not been met. Therefore, we decided that the Plan does not have to pay for the continued SNF stay provided from May 19, 2021, to June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on March 2, 2021.

You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that the PCD was prescribed and used during the enrollee's surgery. The Plan denied your request. The Plan says a PCD used as preventative is not covered and payment would have been included in the facility payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of a joint of the lower extremity (73721) provided on March 2, 2021.
You asked the Plan to waive the copayment for an MRI scan of a joint of the lower extremity. You say that the Plan should have paid for the MRI scan at issue. The Plan denied your request. The Plan says the correct copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $180 copayment for advanced imaging services at locations other than an outpatient hospital. The enrollee has been asked to pay $143.83 for an MRI scan of a joint of the lower extremity. An MRI scan of
a joint of the lower extremity falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that the enrollee has been asked to pay less than or equal to the amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI scan of a joint of the lower extremity (73721) provided on March 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on May 13, 2021.
You asked the Plan to pay for the consultation. You say that you contacted the Plan to confirm whether or not a
tooth extraction would be covered and you were advised that both an extraction and root canal were covered up
to $500.00 per year. The Plan denied your request. The Plan says this service is not a covered benefit under
your dental plan. The Plan also says that consultation benefits were not requested during your call with the
Plan, only benefits for extractions and root canals.
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
consultation (D9310) provided on May 13, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on January 25, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice election at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for services provided from June 10, 2020, to September 11, 2020.

You asked the Plan to waive the cost-sharing for the services. You say that the deductible was met in June 2020, and there should be no charges after this. The Plan denied your request. The Plan says that these claims were processed in accordance with the enrollee's contract, and the enrollee has not been charged any amount greater than the maximum out-of-pocket as indicated in the contract.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there a $250 deductible which applies to certain items and services. Once you have paid your deductible, the Plan will begin to pay their share of the costs for covered medical services and you will pay your share (your copayment or coinsurance amount) for the rest of the plan year or until the combined maximum out-of-pocket amount of $1,500 is met. This is the most you pay during the plan year for covered plan services received from both in-network and out-of-network providers. The amounts you pay for deductibles, copayments, and coinsurance for covered services count toward this combined maximum out-of-pocket amount. If this out-of-pocket maximum is met, you will have no out-of-pocket costs for the rest of the year for covered services.

You say that the enrollee is being charged for services after meeting their limit, and that the plan must have made a calculation error because the enrollee should not be charged after June 2020. The Plan provided documentation showing that the enrollee has been asked to pay a total of $260 in copayment amounts, $990 in coinsurance amounts, and has met their $250 deductible for the 2020 plan year, including the charges for the dates in question. ($260 +$990 + $250 = $1,500). Documentation shows that the enrollee has not been asked to pay any amount in excess of the Plan's 2020 annual out-of-pocket maximum. This means that the payment amounts requested are correct. This cost sharing is a contractual obligation that had not been met at the time the services was received on June 10, 2020 to September 11, 2020. Therefore, we decided that the Plan does not have to waive the cost-sharing for services provided from June 10, 2020, to September 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. You say that the goal is to achieve and maintain remission. The
Plan denied your request. The Plan says the enrollee has not tried and failed Stelara.
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 Entyvio. Our physician reviewer found
that the enrollee has ulcerative colitis. The Plan requires a trial of drug Stelara before they will approve the
requested drug. In this case, the patient has not tried and failed the required drug. There is no documentation
provided indicating that the Plan's required drug would likely be less effective or likely have adverse effects
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 Entyvio have not been met. Therefore, we decided that the Plan does not have
to pre-approve Entyvio.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genesight pharmacogenomic testing (81479) provided on February 24, 2021.
You asked the Plan to pay for Genesight pharmacogenomic testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that the algorithms employed in combinatorial testing are also not currently considered reasonable and necessary components of multi-gene testing.
We looked at the file and Medicare rules. The records identify the testing at issue as combinatorial testing, which is not considered medically necessary. Based on this information, we decided that Medicare rules for coverage of Genesight pharmacogenomic testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight pharmacogenomic testing (81479) provided on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on May 25, 2021.
You asked the Plan to pay for the dental service. You say that it is your understanding that your policy provides coverage for procedures that provide preventive dental care. You say that your dentist advised this service was preventive in nature and that without it you would require a crown. You also say that your dentist advised a crown would not be beneficial as you have no bottom teeth. The Plan denied your request. The Plan says core build up is not listed as a covered service.
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 core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on May 25, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on
January 8, 2021.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says the services were
provided before the authorization was approved.
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 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 physical therapy provided by an out-of-network
provider on January 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra (J0517).

You asked the Plan to pre-approve the Fasenra. The Plan denied your request. The Plan says it was confirmed with the provider that this drug would be purchased from an outside pharmacy.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Fasenra (J0517).

Benefits for the Fasenra 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network practitioner services provided to the enrollee on January 22, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network practitioner services provided to the enrollee on January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the inpatient hospital admission provided
from January 28, 2020, to January 29, 2020.

You asked the Plan to reduce the copayment for the inpatient hospital admission. You say that you should be
charged for an emergency room visit and not an inpatient admission. The Plan denied your request. The Plan
says you have been asked to pay the correct cost-sharing 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 $795
copayment per stay after you pay your $1,000 deductible for in-network hospital care.

You have been asked to pay a $795 copayment for the inpatient hospital admission. The inpatient hospital
admission falls within the "Inpatient hospital care" benefit category. The medical record shows you were
admitted as an inpatient. 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 reduce the copayment for the inpatient hospital admission
provided from January 28, 2020, to January 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease represented by code 99072 provided on February 18, 2021.
You asked the Plan to pay for code 99072. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease represented by code 99072 provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 18, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on May 13, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file shows that the Plan uses Local Coverage Determination (LCD) L38168 to support their denial. However, this LCD is not valid for the appropriate jurisdiction for the provider's billing state of California. Therefore, we are unable to use LCD L38168 to substantiate our decision. There is no documentation in the case file to support that the enrollee had genetic testing of the tumor sample where the quantity of the tissue made testing infeasible or invasive biopsy is medically contraindicated. This means that the Guardant360 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on May 13, 2021.