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

We decided that the Plan does not have to pay for the FoundationOne Liquid Cdx laboratory test provided to the enrollee on July 17, 2021.
You asked the Plan to pay for the services. You say that there have been recent issues with feeling dizzy and "blacking out." The Plan denied your request. The Plan says there is no staging for current diagnosis found.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee who has what appears to be at least a stage III lung cancer has pathology reported as inconclusive and suspicious for neuroendocrine or small cell lung cancer. For this type of caner next generation sequencing is not a standard test and not used for diagnosis. In addition, liquid biopsy per the NCCN Guidelines should be reserved for when inadequate tissue is available for testing. However, this enrollee needs additional tissue to make a diagnosis of the type of cancer. The service is not reasonable or medically 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 pay for the FoundationOne Liquid Cdx laboratory test provided to the enrollee on July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic services (procedure code 97530) provided to the 
enrollee on February 22, 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 Current Procedural Terminology (CPT) code 97530 remains not supported. 
 
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 97530 is "Therapeutic activities, direct (one-on-one) 
patient contact (use of dynamic activities to improve functional performance), each 15 minutes." 
 
 
 
 
 
 
 We find that CPT code 97530 is not supported in the medical record. Specifically, there is a more appropriate 
code to use for occupational therapy in the home. 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 
therapeutic services (procedure code 97530) provided to the enrollee on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the ventricular assist device (VAD) driveline management kit provided 
on August 12, 2021, billed with code Q0509. 
 
You asked the Plan to pay for the VAD driveline management system as billed. You say that this was billed 
correctly for the driveline management system. The Plan denied your request. The Plan says that the rules 
indicate that code Q0508 is the correct code for these supplies. As such, the denial is correct. 
 
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 provided sufficient evidence to support its decision that code 
Q0508 is more appropriate than Q0509 for this device. Based on the Transmittal cited in the Medicare rules 
section, the only difference between these two codes is whether the VAD placement was covered by Medicare 
Part A. The Plan has not provided evidence to support that this patient's device was implanted with Part A 
coverage, which would be required to support the denial. Without this information, we cannot confirm that 
Q0509 is inappropriate for billing for the items provided. Therefore, we decided that the Plan has to pay for the 
ventricular assist device (VAD) driveline management kit provided on August 12, 2021, billed with code 
Q0509.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on April 27, 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 payment is included in the global surgical package.
The Plan must follow Medicare rules. The rules say that post-operative visits are included in the global surgical package. We looked at the file and Medicare rules. The file shows that the office visit was billed within the global surgical package for the surgery performed on March 24, 2021. Payment for the visit is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 13, 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. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 13, 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 , due to the enrollee's ongoing and complex medical needs, he cannot be cared for at a skilled nursing facility. You say that the enrollee is stable and suitable for transfer to an LTACH. The Plan denied your request. The Plan says the guidelines or coverage of LTACH care have not been met. The Plan says that the enrollee's needs can be met in the current hospital setting.
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 the enrollee appears to be improving but is still somewhat unstable and should only require short-term additional acute care services that can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous.
Transfer to a lower level of care may be considered when treatment has completed. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the body fluid pH service (83986) and spectrophotometry
(84311) provided on May 26, 2020.
You asked the Plan to pay for the body fluid pH service and spectrophotometry. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 83986, 84311 and G0482.
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 codes 83986 and 84311 are column II codes to column I code G0482. 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 body fluid pH service (83986) and spectrophotometry (84311) provided on May 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 24, 2017, to December 31, 2017.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says no daily skilled needs were identified.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 24, 2017, to December 31, 2017.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (83789, G0480) rendered by the out-of-network (OON) provider on September 27, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (83789, G0480) rendered by the out-of-network (OON) provider on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the transthoracic echocardiography (TTE) you received on October 22, 2021.
You asked the Plan to waive the copayment for the TTE. You say that you were not aware there would be a copayment for this service. 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 $250 copayment for diagnostic imaging. You have been asked to pay a $250 copayment for the TTE. The TTE falls within the diagnostic imaging 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 transthoracic echocardiography (TTE) you received on October 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor. 
 
You asked the Plan to pre-approve these services. You say that chiropractic care helps you manage your pain 
levels. The Plan denied your request. The Plan says the services are available from network provider. 
 
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 
a referral to an out-of-network chiropractor.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox for the enrollee. 
 
You asked the Plan to pre-approve Botox. You say that the enrollee needs Botox for a diagnosis of spasmodic 
torticollis. The Plan denied your request. The Plan says that there is no clinical reason provided as to why the 
alternatives cannot be used. 
 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 Botox. Our reviewer says that Botox is 
not medically reasonable and necessary. The Plan requires a trial of Xeomin and Dysport before they will 
approve the requested drug. In this case, the patient has not tried and failed the required 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. Our physician reviewer found that the enrollee's condition does not meet 
step therapy criteria for Botox. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on April 
19, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a domiciliary or rest home visit. You say that it is the nursing facility's 
responsibility to get authorization for their patients. You also say that it was medically necessary for the patient 
to receive the treatment by this provider, and you did not know that the facility failed to get preauthorization 
for this patient. The Plan denied your request. The Plan says prior authorization is required from the Plan for 
this disputed service to be covered. The Plan also says that an authorization was not obtained prior to the 
services being rendered and the provider is not participating with the member's Plan. 
 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 a domiciliary or rest home visit (99336) provided 
on April 19, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair for the enrollee.
You asked the Plan to pre-approve a manual wheelchair. You say that the enrollee requires a wheelchair to go longer distances. The Plan denied your request. The Plan says that notes do not mention if other devices have been tried.
The Plan must follow Medicare rules. Medicare rules say that a manual wheelchair can be covered if the Medicare 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 pre-approve a manual wheelchair. Our reviewer says that a manual wheelchair is not considered medically reasonable and necessary in this case. The documentation does support that the patient has a mobility deficit, but it is not clear that the deficit impairs MRADLs in the home and that this mobility limitation is not ameliorated by a walker or a cane. While the patient may have the cognition to safely operate the wheelchair the documentation does not reveal a home assessment to support that the requested device will be able to safely maneuver in the home and access rooms for MRADL participation. The documentation does not support that the manual wheelchair will significantly improve the patient's ability to participate in MRADLs and the patient will use it in the home. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a manual wheelchair. 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 manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because there are not enough records to support the medical necessity of Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for Prolia. Our physician reviewer found the requested use of Prolia is Food & Drug Administration (FDA) approved for the enrollee's condition. The documentation supports that this is safe and effective and otherwise reasonable and necessary 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve use of Prolia.
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 copayments for the extremity venography and the caval 
venography services you received on July 12, 2021. 
 
You asked the Plan to waive the copayments for the two venography services. You say that you thought that if 
you had these services in an office setting that there would be no copayment. The Plan denied your request. 
The Plan says you were charged these copayments 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 $50 
copayment each for non-invasive vascular studies.  
 
You have been asked to pay a $50 copayment each for the two venography services. This is not a copayment 
for the surgery you had on that same day.  The two venography services fall within the non-invasive vascular studies 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 the extremity venography and the caval venography services you 
received on July 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walking boot (L4361) provided on May 7, 2021.
You asked the Plan to pay for a walking boot. You say that you cannot afford to pay for the item at issue. The Plan denied your request. The Plan says rules for payment have not been met because the item at issue is a duplicate of equipment paid for during the previous 5 years for the same anatomical site.
The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment can in no case be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. We looked at the file and Medicare rules. In this case, you are requesting a replacement for a walking boot received by you on August 3, 2020. Therefore, the requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a walking boot have not been met. Therefore, we decided that the Plan does not have to pay for a walking boot (L4361) provided on May 7, 2021.
Your complaint about receiving erroneous or incomplete information about your benefits from representatives of the Plan or of the provider 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.