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

We decided that the Plan does not have to pay for the Tempus xT and xF genetic testing panels provided on June 15, 2021, billed with 10 individual gene codes.
You asked the Plan to pay for the Tempus testing as billed. You say that this is medically necessary testing and was billed correctly. The Plan denied your request. The Plan says this was billed with an invalid place of service code, and also should be billed with a single code.
The Plan must follow Medicare rules. Medicare rules say that correct coding requires that when a panel code is ordered, it should be billed, rather than the individual gene codes. We looked at the file and Medicare rules. The testing provided was ordered as a panel. It is not correct coding to bill individual gene codes in this situation. Based on this information, we decided that Medicare rules for coverage of the Tempus testing as billed have not been met.
Therefore, we decided that the Plan does not have to pay for the Tempus xT and xF genetic testing panels provided on June 15, 2021, billed with 10 individual gene codes.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on October 18, 2021.
You asked the Plan to pay for an abdominal ultrasound. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says the service at issue was not billed as required by Medicare regulations.
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 76705 is a column II code to column I code 93976. 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 an abdominal ultrasound (76705) provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient hospital clinic visit (G0463) provided on November 11, 2021, by an out-of-network provider.
You asked the Plan to pay for an outpatient hospital clinic visit. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
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 an outpatient hospital clinic visit (G0463) provided on November 11, 2021, by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have Morton's Neuroma in both feet. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relistor 150mg tablets.
You asked the Plan to pre-approve the Relistor tablets. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B.
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 Relistor 150mg tablets.
Benefits for the Relistor 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia (CPT code J0129) to treat cellulitis of the lower extremity.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied your request. The Plan says there is no support in the compendia utilized by Medicare or in Medicare approved literature for the use of this medication for the submitted diagnosis.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the medication. Our physician reviewer found the medical records provided and the Medicare-approved major drug compendia, there is no documentation that the requested use of Orencia is Food and Drug Administration (FDA)-approved for the enrollee's diagnosis of cellulitis. There is also no qualifying diagnosis in any of her other available medical history. The use of Orencia for cellulitis is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS)-approved medical journal. The use of Orencia for cellulitis is not indicated, supported or recommended in any of the compendia. The use of Orencia for cellulitis is not safe and effective and otherwise reasonable and necessary for this enrollee as defined by Medicare criteria.
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 medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia (CPT code J0129) to treat cellulitis of the lower extremity.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyaluronan or derivative, GenVisc 850, for intra-articular injection (CPT code J7320).
You asked the Plan to pre-approve the medication. You say that the enrollee had two (2) failed cortisone injections, and the enrollee even tried physical therapy for twelve (12) weeks. The Plan denied your request.
The Plan says the records do not show the enrollee has been on any non-preferred drugs in the past 365 days or tried and had an inadequate response or intolerance to two (2) preferred hyaluronan agents.
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 medication. Our physician reviewer found the enrollee has not tried and failed two (2) of the required/preferred drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Without the support of the documentation, Genvisc 850 is not approved as step 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 the medication have not been met. Therefore, we decided that the Plan does not have to pre-approve hyaluronan or derivative, GenVisc 850, for intra-articular injection (CPT code J7320).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have TO waive the copayment for ambulance services you received on August 28, 2021.
You asked the Plan TO waive the copayment for the ambulance services. You say that it was the Plan's decision to move you to a different hospital, so you should have not to pay for an ambulance that you did not request. The Plan denied your request. The Plan says you were charged this copayment 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 $200 copayment for ambulance services.
You have been asked to pay a $200 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 ambulance services you received on August 28, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the presumptive drug testing services (80307) provided on September
15, 2021.
You asked the Plan to pay for the presumptive drug testing services. You say that you would like
reconsideration because this testing was billed with the appropriate diagnosis code and has not exceeded the
frequency limitation. The Plan denied your request. The Plan says that this service does not meet the frequency
requirements as established in the Local Coverage Determination.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the Plan has not forwarded any evidence to support what frequency
requirement has not benn met. There is no indication that the frequency limitation for presumptive drug testing
has been exceeded. It is the burden of the Health Plan to substantiate their denial with evidence. In this case,
the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan
has to pay for the presumptive drug testing services (80307) provided on September 15, 2021.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).
You asked the Plan to pre-approve Injectafer. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Infed and Venofer before they will approve the requested drug, Injectafer. Based on the medical records provided. the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drug(s) would likely be less effective and/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 Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided October 29, 2021.
You asked the Plan to pay for the bitewing x-rays. You say that you rarely use your dental services and would like this necessary service covered. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the bitewing x-rays once per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were previously covered on June 15, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided October 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiaflex.
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary for the
enrollee's treatment for palmar fascial fibromatosis. The Plan denied your request. The Plan says your provider
has indicated that this drug is being dispensed by a pharmacy - a Part D covered event. The Plan states for the
enrollee's Part B benefit to cover the drug, it must be furnished by the enrollee's physician, an infusion center,
or the hospital outpatient department.
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 Xiaflex.
Benefits for the medication 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 {{enter specific services at issue}} provided on August 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"]. You say that the patient is at an assisted living facility and had first given the facility Medicare and a different Plan insurance at the time, which you are contracted with and were active at the time as well. You also say that after after the patient was seen you were then notified that the patient had this Plan. The Plan denied your request. The Plan says the member was seen for chronic conditions, not urgent or emergent care, and there was no prior-authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 {{enter specific services at issue}} provided on August 3, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Eliquis tablet.
You asked the Plan to pre-approve Eliquis. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Eliquis tablet.
Benefits for Eliquis 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: Hospice
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care provided from October 1, 2020, to October 2,
2020.
You asked the Plan to pay for the evaluation and management services. You say that the services should be
covered under Medicare. The Plan denied your request. The Plan says that the enrollee elected hospice at the
time of service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the file does not include documentation to substantiate the Plan's
denial. Therefore, we decided that the Plan has to pay for subsequent hospital care provided from October 1,
2020, to October 2, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on
October 7, 2021.
You asked the Plan to waive the copayment for outpatient surgery. You say that the treatment should be covered by the Plan with a reasonable copayment. The Plan denied your request. The Plan says the correct copayment was applied to the claim per your 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 a $250 copayment for Medicare-covered outpatient surgery at an ambulatory surgical center.
You have been asked to pay a $250 copayment for the outpatient surgery. The outpatient surgery falls within
the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers benefit category, Medicare-covered outpatient surgery. 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 outpatient surgery provided on October 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for speech/hearing therapy (92507) provided on May 13, 2021,
by an out-of-network (OON) provider.
You asked the Plan to pay for speech/hearing therapy. You say that at the time of service, the patient was
believed to be insured by traditional Medicare, so no authorization was obtained for this service. The Plan
denied your request. The Plan says the rendering provider is a non-participating provider and the attending
provider is also a non-participating provider with the Plan. The Plan also says that they did not authorize any
services for this provider or facility.
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 speech/hearing therapy (92507) provided on May
13, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on October 14, 2021.
You asked the Plan to pay for the eyeglasses. You say that you were told by your physician's office that the
eyeglasses would be covered as you are going blind in your left eye. The Plan denied your request. The Plan
says the service is a covered benefit, but the enrollee has exceeded limits set in the subscriber agreement.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every 2 years.
We looked at the file and the Plan's rules. The file shows that On September 24, 2020, the Plan paid for
eyeglasses provided to you on September 22, 2020. Based on this information, we decided that the Plan's rules
for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for
eyeglasses provided on October 14, 2021.