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

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) rendered on June 28, 2021.
You asked the Plan to waive the copayment for these services. You say that you feel this is copayment stacking. The Plan denied your request. The Plan says the copayment was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment per day for Medicare-covered outpatient diagnostic tests.
Review of the file shows that you received an EKG on June 28, 2021. You have been asked to pay a $10 copayment for these services. These services fall within the Medicare-covered 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 electrocardiogram (EKG) rendered on June 28, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says a step therapy exception cannot be granted. 

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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the plan requires a trial 
of Stelara before they will approve Entyvio. In this case, the enrollee has not tried and failed the required step 
therapy drug. There is no documentation that Stelara would likely be less effective and/or likely to 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 the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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 necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the present setting where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for use of Kcentra (C1932) during cosmetic surgery on June 4, 2020.
You asked the Plan to pay for Kcentra. You say that the treatment at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the treatment at issue was an expense incurred in connection with a cosmetic surgery.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable. 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 Kcentra.
Our reviewer says that the service at issue is not medically reasonable and necessary in this case. Our physician reviewer found that that the enrollee underwent breast implant removal. The record does not document complication from the implants that would indicate a need for the removal. The record indicates that the enrollee was evaluated for cosmetic purposes. The procedure was cosmetic. By Medicare rule, all care related to cosmetic surgery is not covered. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Kcentra have not been met. Therefore, we decided that the Plan does not have to pay for use of Kcentra (C1932) during cosmetic surgery on June 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a biopsy of skin (11100) provided on June 
12, 2017, and a destruction of malignant lesion (17260) provided on August 21, 2017, in an outpatient hospital 
setting. 
 
You asked the Plan to waive the copayments for a biopsy of skin and a destruction of malignant lesion. You 
say that the providing facility is not a hospital and that the coding of the services at issue as outpatient services 
is not fair. The Plan denied your request. The Plan says the correct copayments were 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). Your contract with the Plan clearly says that you must pay a $100 
copayment for Medicare-covered surgery at an outpatient hospital or an ambulatory surgical center. 

In this case, Medicare records confirm that the providing facility is a hospital. You have been asked to pay a 
$100 copayment per date of service for a biopsy of skin and a destruction of malignant lesion. A biopsy of skin 
and a destruction of malignant lesion fall within the "Outpatient Surgery 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 copayments 
for a biopsy of skin (11100) provided on June 12, 2017, and a destruction of malignant lesion (17260) provided 
on August 21, 2017, in an outpatient hospital setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that you are appealing with supporting documentation. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
requested bilevel positive airway pressure (BiPAP) with average volume assured pressure support (AVAPS) 
mode can be provided by a BiPAP device and a ventilator is not covered for this purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered when used to deliver 
positive airway pressure therapy, regardless of the illness treated by the device.  
 
We looked at the file and Medicare rules. A ventilator is not covered for the requested positive airway pressure 
(PAP) therapy with AVAPS mode. The Plan says that they would approve an E0471 BiPAP device upon 
request. Based on this information, we decided that Medicare rules for coverage of ventilator have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate.
You asked the Plan to pre-approve transurethral waterjet ablation of the prostate. You say that you are
appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is
correct, because the enrollee is over 80 years of age.
The Plan must follow Medicare rules. Medicare rules say that transurethral waterjet ablation of the prostate
may be covered if certain criteria are met, including that the enrollee is age 80 or less.
We looked at the file and Medicare rules. The enrollee is 81-years old and is therefore not age 80 or less. Based
on this information, we decided that Medicare rules for coverage of transurethral waterjet ablation of the
prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral
waterjet ablation of the prostate.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says radiofrequency ablation used for sacroiliac joint pain is considered not medically necessary and investigational.
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 this procedure is considered experimental and investigational due to the wide variation in efficacy reported in the peer-reviewed literature. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation for the enrollee.
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 you need IRF care due to the amputation of your leg. The Plan denied your request. The Plan says based on Medicare guidelines, your request for an IRF admission does not meet the requirement for approval.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you need to recover more before returning home. 
The Plan denied your request. The Plan says that you can be treated at a lower level of care, 
 
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 pre-approve SNF care. Our reviewer says that the 
requested SNF care is medically necessary. Our physician reviewer found the records show that you have 
documented skilled therapy needs. You have not yet been shown to have reached a plateau in function.  Daily 
skilled services are required to establish a maintenance program or to prevent deterioration of your condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen collection (45378) provided on June 16, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this colonoscopy was required to investigate the results of a previous colonoscopy and should be covered in full. The Plan denied your request. The Plan says you are responsible for a $290 copayment for outpatient surgery services. The colonoscopy in question is diagnostic in nature, as it was provided to investigate signs or symptoms identified by your physician during a previous colonoscopy.
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 $290 copayment for outpatient surgery services. A diagnostic colonoscopy is performed in order to explain symptoms identified by your physician, because you've had a previous colonoscopy that resulted in a removal of polyps, or other colorectal related conditions. If your physician orders a diagnostic colonoscopy, cost sharing will apply. You have been asked to pay a $290 copayment for the diagnostic colonoscopy. The colonoscopy was billed as a diagnostic service and was not provided for screening purposes. The procedure code in question, code 45378, is classified as a surgical procedure. 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 diagnostic colonoscopy with specimen collection (45378) provided on June 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore Assay testing provided on May 12, 2021.  

You asked the Plan to pay for the 4Kscore Assay testing. You say that the referring physician determined that 
this test was medically necessary for the enrollee. The Plan denied your request. The Plan says the local 
coverage determination (LCD) article L37122 states that 4Kscore testing is not reasonable, necessary, and is 
not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that due to significant issues with assay validation 
and absence of clinical utility, 4Kscore testing is not reasonable and necessary and is not covered by Medicare.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the 4Kscore Assay testing have not been met. Therefore, we decided that the Plan does not have to 
pay for the 4Kscore Assay testing provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services provided on March 16, 2021.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says that the initial processing of this claim was correct, and documentation supplied did not support adjustments.
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 submitted documentation to support why the claim was denied or the rules to support the denial. Therefore, we decided that the Plan has to pay for physician's services provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the observation care discharge service (99217) provided on May 14, 2021.
You asked the Plan to pay for code 99217. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not supported.
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 denied payment for the observation services (99217) because a qualifying initial or subsequent observation stay (99218-99220 or 99224-99226) has not been reported. However, the file does show that code 99219 was reported on May 13, 2021, which is a code that represents an initial observation care service was provided. The Plan did not provide any evidence based on Medicare guidelines that the initial observation care service provided was not valid. Therefore, we decided that the Plan has to pay for the observation care discharge service (99217) provided on May 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging (MRI) 70551 provided on May 
29, 2021. 
 
You asked the Plan to pay for MRI 70551. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of payment for this service is correct, because code 70551 has a 
procedure-to-procedure (PTP) modifier of 1 with code 70553 meaning that this code is not separately payable 
without an appropriate modifier. 
 
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 MRI 
70551 has a bundled relationship with code 70553 and cannot be paid as billed. This code cannot be paid as a 
separate line item without an appropriate modifier, which was not billed on this claim. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for magnetic resonance imaging (MRI) 70551 provided on May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for comprehensive audiometry evaluation (92557) provided June 22, 2021.
You asked the Plan to waive the copayment for the hearing exam. You say that this was a routine hearing exam and not a diagnostic hearing exam. The Plan denied your request. The Plan says this claim was processed with the correct cost share 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 $10 copay per visit for Medicare covered diagnostic hearing. You have been asked to pay $10 copay per visit for the hearing exam. The hearing exam falls within the Hearing services 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 comprehensive audiometry evaluation (92557) provided June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87634, 87640, 87798) provided on September 3, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this testing is used for clinical purposes. The 
Plan denied your request. The Plan says this was not billed with the correct place of service.

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 (87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87634, 87640, 87798) provided on September 3, 2020.