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

 We decided that the Plan does not have to pre-approve Invokamet XR tablets.  You asked the Plan to pre-approve Invokamet XR tablets. The Plan denied your request. The Plan says Invokamet is not a covered benefit under the enrollee's plan.  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 Invokamet XR tablets.          Benefits for Invokamet XR tablets 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 the lab services provided on February 4, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.  We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (64450) provided on April 12, 201.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 64450 is a column II code to column I code 01402. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (64450) provided on April 12, 201.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 reader.  You asked the Plan to pre-approve the FreeStyle Libre 2 reader. You say that you say that the enrollee has neuropathy and at times has a hard time testing his blood sugars by finger-sticks. The Plan denied your request. The Plan says the enrollee does not meet the requirements for covering this product.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.     We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre 2 reader have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 reader.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lucentis (J2778).  You asked the Plan to pre-approve Lucentis. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, bevacizumab.  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 Lucentis. Our reviewer says that the step therapy criteria has not been met. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The reviewer found that the provided documentation does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. Therefore, the reviewer found that the step therapy criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Specifically, the file does not indicate that the enrollee has tried and failed the plan's preferred step one alternative. Therefore, we decided that the Plan does not have to pre-approve Lucentis (J2778).
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428 x 2) and ground mileage (A0425 x 2) provided on July 2, 2021.  

You asked the Plan to pay for the transportation services. You say that the 2 separate transports were medically necessary. The Plan denied your request. The Plan says the services were not medically necessary.  

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   

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 transportation services. Our reviewer says that the transportation services were not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee was transported from a medical center to assisted living facility. The reviewer found that the record indicates that the enrollee was transported via stretcher. The reviewer found that the record does not indicate that the enrollee's clinical condition is such that other methods of transport are contraindicated. Therefore, the reviewer found that 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 the transportation services have not been met. Specifically, the file does not show that the enrollee's clinical condition is such that other methods of transport are contraindicated. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428 x 2) and ground mileage (A0425 x 2) provided on July 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466).  You asked the Plan to pre-approve a ventilator. You say that please see attachments for supporting documentation for the enrollee's health condition. The Plan denied your request. The Plan says the requested home ventilator cannot be considered reasonable and necessary per Medicare coverage criteria.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee has severe COPD, with recent exacerbations and acute hypoxic and hypercarbic respiratory failure. The enrollee may benefit from BiPAP support at night. There is no documentation of BiPAP failure in the home setting. The enrollee improved on BiPAP in the hospital. BiPAP with AVAPS has not been tried. Medicare does not cover a home ventilator when used as BiPAP.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell) (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessories (E0673) provided on July 2, 2021.  You asked the Plan to pay for a pneumatic compression device and accessories. You say that these items were medically necessary. The Plan denied your request. The Plan says these items are not covered.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  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. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675) and accessories (E0673) provided on July 2, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health aide (HHA) services (S9122) provided from June 7, 2021, to August 25, 2021.  You asked the Plan to pay for the HHA services. You say that the treating providers have not opted out or been precluded from Medicare. The Plan denied your request. The Plan says you received HHA services from providers who are not under contract with the Plan and are not certified for Medicare.    The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services, a provider or supplier must be enrolled in the Medicare program.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the HHA services have not been met. This provider is not part of the Medicare program and is not payable. Therefore, we decided that the Plan does not have to pay for the home health aide (HHA) services (S9122) provided from June 7, 2021, to August 25, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve GenVisc-850.  You asked the Plan to pre-approve GenVisc-850. You say that this drug is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage of this drug have not been satisfied.  The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy is subject to the criteria listed 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 GenVisc-850. Our reviewer says that the requested drug is not medically reasonable and necessary based on the Medicare coverage criteria. Our physician reviewer found that the record indicates that the enrollee has osteoarthritis of the knees and has three meniscal tears repaired in the past. The record does not contain radiographic demonstration of osteoarthritis or the documentation of failure of three months or more of conservative nonpharmacologic therapy. Step therapy exemption cannot be granted because coverage rules for the service are not satisfied. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GenVisc-850 have not been met. Therefore, we decided that the Plan does not have to pre-approve GenVisc-850.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (71045) provided on September 15, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (71045) provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the anesthesia service provided on June 29, 2021.  You asked the Plan to waive the copayment for the anesthesia service. You say that you were never informed there would be an extra charge for getting the injection done with an anesthetic. 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 $35 copayment for services obtained from a specialist.    You have been asked to pay a $35 copayment for the anesthesia service. The anesthesia service falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the anesthesia is considered a separate physician service.  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 anesthesia service provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 31, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Gene Sight Psychotropic test provided on July 15, 2021.  You asked the Plan to pay for the Gene Sight Psychotropic test. 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.  The test at issue in this appeal, the Gene Sight Psychotropic test, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. In addition, the appropriate DEX Z-Code identifier was not entered adjacent to the CPT code in the comment/narrative field. Therefore, we decided that the Plan does not have to pay for the Gene Sight Psychotropic test provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99396) provided on June 24, 2021.  

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.  

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "N" under the Physician Fee Schedule indicates that the code in question is non-covered.   

We looked at the file and Medicare rules. Code 99396 is assigned a status indicator of "N" under the Physician Fee Schedule. This is not a covered code. 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 the services (99396) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an electroencephalogram (EEG) and the digital analysis of the EEG (99072,95813, 95957) provided on September 13, 2021.  You asked the Plan to waive the deductible for an electroencephalogram (EEG) and the digital analysis of the EEG. You say that no one told you that you are going to be responsible before having the test done. You also say that you were advised that the procedure was covered, but there was no mention about your responsibility and now you are stuck with a bill that you cannot afford. The Plan denied your request. The Plan says you were charged the correct amount.  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 $1,000 deductible which applies to outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay $712.84 for an electroencephalogram (EEG) and the digital analysis of the EEG . An electroencephalogram (EEG) and the digital analysis of the EEG fall within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 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 electroencephalogram (EEG) and the digital analysis of the EEG was received on September 13, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an electroencephalogram (EEG) and the digital analysis of the EEG (99072,95813, 95957) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation (CPT code 00562) provided to the enrollee on January 26, 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 supported by the records.  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 asked our coder 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 service. Our reviewer found the documentation submitted did not include documentation of Anesthesiology records (January 26, 2021) for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation anesthesia record with anesthesia start and stop time. Therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. The review has determined that the service (CPT code 00562) is not supported by the medical records provided.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all noncoronary bypass procedures (eg, valve procedures) or for re-operation for coronary bypass more than 1 month after original operation (CPT code 00562) provided to the enrollee on January 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve UT elbow supports and a power seat elevation feature for the enrollee.  You asked the Plan to pre-approve UT elbow supports and a power seat elevation feature. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the seat elevator is not covered, and elbow supports are already covered.  The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.  The file shows that the enrollee has been approved for adjustable elbow support hardware. Adjustable elbow support hardware serves the same purpose as UT elbow supports. A power seat elevation feature is non-covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve UT elbow supports and a power seat elevation feature for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a magnetic resonance angiography (70551) provided on September 11, 2021.  You asked the Plan to pay for a magnetic resonance angiography. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this 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 70551 is a column II code to column I code 70554. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance angiography (70551) provided on September 11, 2021.