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

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, Synvisc-One 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81405, 81403, 81406) provided April 26, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support that these services were distinct from services already paid by the plan.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. Only limited clinical records were provided. The provided records do not detail the treating physician discussing the tests with the enrollee or ordering the tests at issue. 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 lab services (81401, 81405, 81403, 81406) provided April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the outpatient surgical services and Part B drugs rendered on May 26, 2021.
You asked the Plan to waive the cost sharing for these services. You say that you have the Plan coverage to supplement what Medicare does not cover. The Plan denied your request. The Plan says the cost sharing 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 $15
copayment for each in-network ambulatory surgical center visit and a 20% coinsurance for Medicare Part B drugs. You can find this information on page 105 of the 2021 EOC.
Review of the file shows that you received outpatient surgical services at an ambulatory surgical center on May 26, 2021. You have been asked to pay a $15 copayment for these services. These services fall within the in-network ambulatory surgical center visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received Medicare Part B drugs on May 26, 2021. You have been asked to pay a 20% coinsurance for these services, for a total of $121.20. These services fall within Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The total amount you have been asked to pay for these services is $136.20. 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 cost sharing for the outpatient surgical services and Part B drugs rendered on May 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 21, 2021.
You asked the Plan to waive the copayment for the emergency ambulance services. You say that you had a terrible accident, and the situation was out of your control. 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 $290 copayment per date of service regardless of the number of trips for emergency ground ambulance services.
You have been asked to pay a $290 copayment for the emergency ambulance services. This service falls within the Ambulance 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 the ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on May 4, 2021.
You asked the Plan to pay for the dental service. You say that you cannot afford to pay this bill. The Plan denied your request. The Plan says unspecified preventive service is not listed as a covered service. The Plan also says that you did not contact the plan prior to the date of service to verify benefits and provider eligibility.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the unspecified preventive service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified preventive service (D1999) provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (73630-LT) provided March 25, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 73630-LT is complete radiologic examination (minimum 3 views) of the left foot. We find that CPT code 73630-LT is not supported in the medical record. Specifically, no radiology report was submitted to support that this service was performed. Based on this information, we decided that Medicare
rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (73630-LT) provided March 25, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for novel Coronavirus testing (0241U) provided on April 12, 2021.
You asked the Plan to pay for the novel Coronavirus testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment for this service is the responsibility of the facility.
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 of a facility claim including the date the member was admitted. The record does not include any indication regarding a surgical procedure. There is no evidence that this testing was rendered prior to surgery. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for novel Coronavirus testing (0241U) provided on April 12, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray provided on May 26, 2021.
You asked the Plan to pay for the intraoral x-ray. You say that you paid $83 already and you better not get a bill. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray provided on May 26, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing (81309, 81321, 81408, 81314) provided from March 9, 2021, to March 13, 2021.
You asked the Plan to pay for genetic testing. You say that this should be covered. The Plan denied your request. The Plan says that this is experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 genetic testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found as a standard of care metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite Instability (MSI) or Mismatch Repair (MMR) Testing. Per the National Comprehensive Cancer Network (NCCN) Guidelines, these tests can be done individually or as part of next-generation sequencing (NGS) panel. Universal genetic testing is recommended on all colon cancer tumors and NGS allows for initial screening with MSI testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have been met. Therefore, we decided that the Plan has to pay for genetic testing (81309, 81321, 81408, 81314) provided from March 9, 2021, to March 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 daily skilled services are not necessary. Our physician reviewer found based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Records do not clarify that you are not appropriate to continue treatment in the acute inpatient rehabilitation facility until you are stable to transfer to home with home health care. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from June 3, 2021, to June 6, 2021.
You asked the Plan to pay for the self-administered drugs. You say that you were told that the procedure and hospital stay would be covered by your insurance. You say that the self-administered drugs would be covered by your insurance too. You say that you do not have the funds to pay for the self-administered drugs on top of the copayment you owe. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under 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 pay for the self-administered drugs provided in an outpatient setting from June 3, 2021, to June 6, 2021.
Benefits for the self-administered drugs 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: Favorable

We decided that the Plan has to pre-approve radiation therapy.
You asked the Plan to pre-approve radiation therapy. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found with 1 metastatic lesion from cancer, it is an accepted standard to address it with local therapy (resection or stereotactic body radiation therapy (SBRT)) which is a notion supported by national consensus guidelines. The LCD criteria appear to be 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 radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm (13132) provided March 16, 2021.
You asked the Plan to waive the copayment for the wound repair. You say that the procedure was small and should not be considered a surgery. 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 $250 copayment per day for outpatient procedures and services, including but not limited to, outpatient surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $250 copayment for the wound repair. Would repair falls within the Outpatient hospital 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 the repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm (13132) provided March 16, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the outpatient clinic visit provided on November 25, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.
The rules say that Medicare Advantage plans may not impose any prior authorization or other utilization management requirements with respect to COVID-19 testing and testing-related services, such as office visits. You can find this information in Section 6003 of the Families First Coronavirus Response Act (FFCRA). The Plan issued their denial as prior authorization was not obtained for the service provided in this case. However, the office visit provided resulted in COVID-19 testing. Medicare rules state that Medicare Advantage plans may not impose any prior authorization or other utilization management requirements with respect to this testing and testing related services, such as office visits. Therefore, we decided that the Plan has to pay for the outpatient clinic visit provided on November 25, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the MRI provided on May 27, 2021.
You asked the Plan to pay for the MRI. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. The claim submitted has the incorrect POS code per Medicare payment criteria. Therefore, we decided that the Plan does not have to pay for the MRI provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for left shoulder pain.
You asked the Plan to pre-approve Hyaluronan or derivative, gel-one (J7326). You say that the enrollee wants to pursue conservative treatment at this time. The Plan denied your request. The Plan says Medicare does not recognize the use of Gel-One for injection in the shoulder joint.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyaluronan or derivative, gel-one (J7326) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection for left shoulder pain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the exercise class, nutrition class, and substance intervention services rendered on April 26, 2021.
You asked the Plan to pay for these services. You say that you were referred to the obstetrician for a mammogram. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.
We looked at the file and Medicare rules. Billed procedure codes H0050 (intervention services), S9451 (exercise class) and S9452 (nutrition class) have a status indicator of I and are not valid for Medicare purposes. These services are not covered. Therefore, we decided that the Plan does not have to pay for the exercise class, nutrition class, and substance intervention services rendered on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on February 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim originally denied for not meeting Medicare NCD/LCD criteria, but no prior authorization was obtained.
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 the injection provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided April 1, 2021.
You asked the Plan to pay for lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel for symptomatic patients with suspected or documented cardiovascular disease. We looked at the file and Medicare rules. The service at issue was cardiovascular risk assessment testing. This is not a covered service. Based on this information, we decided that Medicare rules for coverage of lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81407, 81408, 81479) provided April 1, 2021.