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

We decided that the Plan has to pay for the Guardant360 testing provided on September 1, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that this was ordered by a network provider to assist in treatment decision making. The Plan denied your request. The Plan says that there is no evidence that the enrollee is eligible for any further treatments of his condition for which this testing is needed.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the Guardant360 testing by a contract provider. The file does not show that the plan provided notice that the Guardant360 testing would not be covered. Under Medicare rules, this means the Guardant360 testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for the Guardant360 testing provided on September 1, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ophthalmology office visit provided on June 23, 2021.
You asked the Plan to waive the copayment for specialist visit. You say that this was a routine exam so you should only have to pay $15 copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $40 copayment for ophthalmology office visit. The record shows that this visit addressed a non-routine diagnosis; therefore, the routine eye exam copayment does not apply to this visit.
You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the Vision Care 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 an ophthalmology office visit provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an X-Ray examination provided on August 5, 2021.
You asked the Plan to waive the cost-sharing for X-Ray exam. You say that you never saw this doctor on this date of service. The Plan denied your request. The Plan says the cost-sharing amount you are being charged is correct.
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 $50 copayment for in-network X-Ray. You have been asked to pay $10, which is less than the $50 copayment for X-Ray exam. X-Ray exam falls
within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 cost-sharing for an X-Ray examination provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a primary care office visit provided on May 12, 2021.
You asked the Plan to waive the copayment for office visit. You say that this visit never happened. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 copayment for in-network primary care office visit. The record shows that you received a primary care office visit on this date of service; therefore, the primary care copayment applies to this claim. You have been asked to pay $10 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a primary care office visit provided on May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) cytopathology testing provided on April 1, 2021, billed with code 88120.
You asked the Plan to pay for the FISH testing. You say that this is medically necessary testing. The Plan denied your request. The Plan says this type of testing is not covered for screening for enrollees with hematuria.
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. This FISH testing was provided for a diagnosis of "other abnormal findings in urine". There is no detail regarding these findings or any other signs/symptoms of disease. As such, this FISH testing is considered to be screening in nature. Therefore, we decided that the Plan does not have to pay for the fluorescence in situ hybridization (FISH) cytopathology testing provided on April 1, 2021, billed with code 88120
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound, retroperitoneal (eg, renal,
aorta, nodes), real time with image documentation; limited (76775) provided March 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you don't agree with the cost
share. 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 $50
copayment for diagnostic procedures and tests, including ultrasounds, at all locations of service.
You have been asked to pay a $50 copayment for the ultrasound. The ultrasound falls within the Outpatient
diagnostic tests and therapeutic services and supplies 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 ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation;
limited (76775) provided March 30, 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. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 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: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667 x2) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652 x2), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says that there has been no documented trial of conservative therapy demonstrating failed response to treatment with a PCD coded as E0650 or E0651 for 4 weeks which is required under the Medicare coverage criteria.
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 DME. Our physician reviewer found the review indicates that there has been documentation of unsuccessful trial of conservative therapy and a failed response to treatment with a PCD coded as E0650 or E0651 for 1 week as they could not tolerate its use, which is required under the Medicare coverage criteria. The review has determined that the medical records provided meet the requirements listed in the LCD/NCD for Medicare coverage. 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 DME have been met. Therefore, we decided that the Plan has to pre-approve segmental pneumatic appliance for use with pneumatic compressor (CPT code E0667 x2) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652 x2), for the enrollee.
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 pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that you are in severe pain and need this injection
right away. The Plan denied your request. The Plan says the benefit for radiofrequency ablation has been
exhausted for the year.
The Plan must follow Medicare rules. Medicare rules say that radiofrequency ablation is limited to two
procedures per year.
The medical records show that the same procedure was received on May 14, 2021, and May 20, 2021. Based
on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore,
we decided that the Plan does not have to pre-approve radiofrequency ablation
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.
You asked the Plan to pre-approve a stair lift. You say that you will need this equipment to return home after
surgery. The Plan denied your request. The Plan says that stair lifts are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec tablets.
You asked the Plan to pre-approve Nurtec. You say that the enrollee needs this medication due to vascular concerns. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Nurtec tablets.
Benefits for Nurtec 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 treatment with Ziextenzo (Q5120).
You asked the Plan to pre-approve Ziextenzo. You say that the requested drug is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested drug has been prescribed for an off-label and medically unaccepted use.
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 Ziextenzo. Our reviewer says that the
requested treatment is not medically reasonable and necessary in this case. Our physician reviewer found that
the enrollee is receiving the chemotherapy regimen of Capecitabine, Oxaliplatin, and Trastuzumab, considered
a low-risk regimen with the risk of febrile neutropenia of less than 10%.
The record indicates that the enrollee is not neutropenic or febrile. The FDA has not stated that the requested
drug is indicated for the enrollee's condition. The Medicare-approved cancer drug compendia do not contain a
supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from
Medicare-approved cancer journals were submitted for review.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Ziextenzo (Q5120).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography scan (70450) provided on August 20, 2021.
You asked the Plan to pay for a computed tomography scan. 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 70450 is a column II code to column I code 70496. 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 computed tomography scan (70450) provided on August 20, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor (CGM) supply allowance provided on July 20, 2021.
You asked the Plan to pay for the CGM supply allowance. You say that this should be paid. The Plan denied your request. The Plan says that payment was already made within an overlapping period for this code.
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. It is noted that an audit found that another provider was also paid for this supply allowance on the same date of service. However, the Plan neglected to forward any evidence that there was a payment made for these services to this or any other provider. The provider did submit evidence of an order as well as proof of delivery for this claim. We find that the denial of payment is not substantiated. Therefore, we decided that the Plan has to pay for the continuous glucose monitor (CGM) supply allowance provided on July 20, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on February 16, 2021.
You asked the Plan to waive the copayment for these services. You say that the nurse was unable to draw blood and advised the enrollee go to another facility. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment per day for other Medicare-covered laboratory tests that are not FIT tests.
Review of the file shows that the enrollee received laboratory services on February 16, 2021. The enrollee has been asked to pay a $10 copayment for these services. These services fall within the other Medicare-covered
laboratory tests that are not FIT tests benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laboratory services rendered on February 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on June 22, 2021.
You asked the Plan to pay for the dental services. You say that you went to the dentist to keep the tooth from getting an infection. You say that the treatment is needed twice per year. You also say that the treatment is medically necessary. The Plan denied your request. The Plan says localized delivery of antimicrobial agents is not listed as a covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the localized delivery of antimicrobial
agents is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON medical services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are network providers able to provide the requested services.
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 medical services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).
You asked the Plan to pre-approve the interspinous spacer placement procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is non-covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the interspinous spacer placement procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental at this time. More research is needed to show safety and efficacy. 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 interspinous spacer placement procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement procedure (22869).