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

We decided that the Plan does not have to pay for 4Kscore testing provided on June 30, 2021.

You asked the Plan to pay for 4Kscore testing. You say that this testing was medically necessary as ordered by 
the referring physician. The Plan denied your request. The Plan says the denial of payment for this testing is 
correct, because this testing did not meet coverage criteria.

The Plan follows Medicare rules. Medicare rules state that 4Kscore testing may be covered if certain criteria 
are met.

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 4Kscore testing. Our reviewer says that this 
testing does not meet the criteria for coverage. Our physician reviewer found the 73-year old enrollee had an 
elevated prostate-specific antigen (PSA). There is no documentation indicating the presence of both no other 
relative indication for prostate biopsy and no relative contraindication to prostate biopsy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4Kscore testing have not been met. Therefore, we decided that the Plan does not 
have to pay for 4Kscore testing provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for computed tomography, thorax (71250) computed tomography, abdomen and pelvis (74176) provided August 25, 2021.  

You asked the Plan to waive the copayment for the diagnostic services. You say that you feel that the service should be covered and feel the copay should be waived or changed. It was a follow up after getting out of the hospital. The Plan denied your request. The Plan says this claim was processed with the correct copayment 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 $250 per day for other Medicare covered diagnostic radiology services that are not ultrasounds.   

You have been asked to pay $250 for the diagnostic services. The diagnostic service falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for computed tomography, thorax (71250) computed tomography, abdomen and pelvis (74176) provided August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the amalgam (D2161) provided on tooth # 12 on August 16, 2021.  

You asked the Plan to pay more for the amalgam. You say that you did not know until you contacted the Plan about this bill that white fillings are not covered. You also say that you feel this bill should be covered at 50% due to the misinformation on your coverage. The Plan denied your request. The Plan says the Plan's payment of $30.50 is correct per the health plan benefit contract. 

 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 Plan only covers restorations on anterior teeth and the buccal surface of bicuspids. The record shows that you received the resin-based composite of four or more surfaces (D2394) on tooth #12, which is a bicuspid tooth and more than only the buccal surface, which is why you are being charged for the amalgam. The Plan paid the allowed amount for the amalgam ($211) minus the Deductible ($50), times the benefit co-insurance (50%), minus the office visit co-pay ($50) which equals the Plan's net payment ($30.50). You are responsible for the difference between the allowed amount for the white filling ($309) and the Plan's net payment of $30.50, which totals your responsibility of $278.50. Therefore, we decided that the Plan does not have to pay more for the amalgam (D2161) provided on tooth # 12 on August 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation (CPT code 76377) provided to the enrollee on April 22, 2021.  

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76377 and 70547. This PTP edit has a modifier indicator of 0, which indicates there are no modifiers that are allowed with this PTP code pair. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation (CPT code 76377) provided to the enrollee on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Breztri Aerosphere.

You asked the Plan to pre-approve Breztri Aerosphere. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Breztri Aerosphere.

Benefits for Breztri Aerosphere 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cancer panel testing provided on September 18, 2020.

You asked the Plan to pay for hereditary cancer panel testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing was not billed correctly.

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 documentation submitted does not include a physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of hereditary cancer panel testing have not been met. Therefore, we decided that the Plan does not have to pay for hereditary cancer panel testing provided on September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient services provided from June 15, 2020, through June 24, 2020.  You asked the Plan to pay for inpatient services. The Plan denied your request. The Plan says during the audit of this claim an itemized bill was requested and not provided and therefore, the claim was partially denied. Upon appeal, the itemized bill was not provided after multiple attempts to obtain.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.      We looked at the file and Medicare rules. The file shows that you did not submit an itemized bill to justify payment of the claim Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services provided from June 15, 2020, through June 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography of the lumbar spine (procedure code 72131) provided to the enrollee on April 19, 2021.  

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 the denied code is inclusive to another code.  

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 72131 is "Computed tomography, lumbar spine; without contrast material."

  We find that CPT code 72131 is not supported in the medical record. Specifically, this procedure is considered inclusive to CPT 63005. 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 computed tomography of the lumbar spine (procedure code 72131) provided to the enrollee on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on September 11, 2021.

You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says hearing aid must be purchased through the Plan's hearing aid provider to be covered under the hearing aid services offered by the member's Plan.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only ordered through the Plan's hearing provider. 

We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on September 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (80307, G0483) provided on August 11, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you would like for the Plan to reconsider the claim payment. The Plan denied your request. The Plan says the services performed by a non-participating provider were not authorized by the Plan and were ordered by a non-participating provider. The Plan also says that the medical records provided to them do not reveal any medically urgent or emergent 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 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 laboratory services (80307, G0483) provided on August 11, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an X-ray of the hips and laboratory blood tests provided on February 18, 2021.  

You asked the Plan to waive the deductible for an X-ray of the hips and laboratory blood tests. You say that a representative of the Plan told you that you do not owe the amount at issue. The Plan denied your request. The Plan says the correct cost-sharing was applied.  

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 is a $500 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies.   

The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an X-ray of the hips and laboratory blood tests was received on February 18, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an X-ray of the hips and laboratory blood tests provided on February 18, 2021.   

Your complaint about receiving erroneous or incomplete information from a representative of the Plan about your cost-sharing responsibilities 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on June 13, 2021, through June 22, 2021 and billed with Diagnosis Related Grouping (DRG) code 193.  

You asked the Plan to pay for the inpatient hospital services billed with DRG 193. You say that you would like reconsideration because the documentation submitted supports the billed DRG code. The Plan denied your request. The Plan says the documentation submitted does not support the diagnosis of Acute Respiratory Failure with Hypoxia.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.   

In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 inpatient hospital services billed with DRG 193. Our reviewer says that the documentation did not support a secondary diagnosis of Acute Respiratory Failure with Hypoxia. Our physician reviewer found the documentation supported an admission for Unspecified Bacterial Pneumonia. The documentation was unclear regarding a diagnosis of Acute Respiratory Failure with Hypoxia. Supporting medical record documentation was not found within the record.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on June 13, 2021, through June 22, 2021 and billed with Diagnosis Related Grouping (DRG) code 193.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  
   
 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Zolmitriptan.  You asked the Plan to pre-approve Zolmitriptan. You say that this drug is medically necessary and reasonable for the enrollee's condition. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.  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 Zolmitriptan.   Benefits for Zolmitriptan 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra.  You asked the Plan to pre-approve Xiidra. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.  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 Xiidra.   Benefits for Xiidra 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 pre-approve the ultrasound exam of esophagus, stomach, and/or upper small bowel (43259) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the ultrasound services. You say that it is medically necessary for this OON provider to provide this medical service. The Plan denied your request. The Plan says the Plan has in-network providers available to provide this 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the ultrasound exam of esophagus, stomach, and/or upper small bowel (43259) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Xofigo.

You asked the Plan to pre-approve Xofigo. You say that this drug is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Xofigo. Our reviewer says that the
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer
found the enrollee is a 73-year-old diagnosed with prostate cancer metastatic to the bone. They had surgery in
2007 and has received CyberKnife treatment. In addition, they have been treated with Taxotere, Zytiga,
Jevtana, and Pembrolizumab. In this case, Xofigo is FDA-approved for the enrollee's condition as the patient
has bone only symptomatic disease. This request is medically reasonable and 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 Xofigo have been met. Therefore, we decided that the Plan has to pre-approve
Xofigo.

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.