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

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 21, 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 this is done for screening purposes.  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 diagnostic codes do not substantiate the service (CPT 88120. The medical records do not indicate that the enrollee has or has had urothelial cancer. FISH testing is not considered a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of this test.  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 laboratory services provided to the enrollee on April 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vision care exam (92004) provided on August 17, 2021.

You asked the Plan to waive the copayment for the vision care exam. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $45 copayment for Vision care.

You have been asked to pay a $45 copayment for a vision care exam. 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 vision care exam (92004) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) rendered by the out-of-network (OON) provider on July 29, 2021.

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 the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) rendered by the out-of-network (OON) provider on July 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81479) provided on March 10, 2021.  You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan denied your request. The Plan says insufficient records were provided to support that this service provided out-of-network was medically necessary or emergent. The service was not pre-authorized.  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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (81479) provided on March 10, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99284) provided on October 19, 2021.  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  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 $90 copayment for each emergency care visit.   You have been asked to pay a $90 copayment for the emergency care visit provided. 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 emergency room visit (99284) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that providers/suppliers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Prolia. Our reviewer says that the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. Our physician reviewer found the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternatives. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower extremity study (93926) rendered by the out-of-network (OON) provider on September 28, 2021.
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 the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the lower extremity study (93926) rendered by the out-of-network (OON) provider on September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) electrical stimulation (unattended) (97014) vasopneumatic device (97016) manual electrical stimulation (97032) therapeutic procedure (97112) subcutaneous and intramuscular injection (96372) unclassified drug (J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) vitamin B-12 injection (J3420) levocarnitine injection (J1955) and compound drug, not otherwise classified (J7999) provided May 4, 2021.

You asked the Plan to pay for the outpatient services. You say that you disagree with the findings and is appealing with medical records, medical articles, medical studies as well as the FDA approval letter, 510k summary. The Plan denied your request. The Plan says the services are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for electrical stimulation (G0283) electrical stimulation (unattended) (97014) vasopneumatic device (97016) manual electrical stimulation (97032) therapeutic procedure (97112) subcutaneous and intramuscular injection (96372) unclassified drug (J3490) thiamine injection, 100 mg (J3411) pyridoxine injection, 100 mg (J3415) vitamin B-12 injection (J3420) levocarnitine injection (J1955) and compound drug, not otherwise classified (J7999) provided May 4, 2021.
Appeal type: Step-Therapy
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 treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment 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 drugs 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a transluminal dilation of aqueous outflow canal (66174) performed on November 25, 2019.  You asked the Plan to pay for a transluminal dilation of aqueous outflow canal. You say that the service at issue was a necessity for the enrollee's care. The Plan denied your request. The Plan says medical necessity rules for payment for the service at issue have not been met.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a transluminal dilation of aqueous outflow canal have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a transluminal dilation of aqueous outflow canal (66174) performed on November 25, 2019.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on January 28, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this service is excluded from coverage.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genetic cardiovascular screening testing does not meet the definition of cardiovascular disease screening, and thus is excluded from 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to the enrollee on January 28, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on November 12, 2021.

You asked the Plan to waive the copayment for the emergency room visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.

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 $90 copayment for Emergency care.

You have been asked to pay a $90 copayment for an emergency room visit. Your contract with the Plan states that the cost-sharing for emergency care is only waived if you are admitted into the hospital for the same condition within 24 hours. 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 emergency room visit provided on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on April 29, 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 code 88120 is not a Medicare benefit for the diagnoses listed on the claim and is done for screening purposes.

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 there is no medical necessity for the FISH testing (CPT 88120) in this case. The records do not indicate that the enrollee has a history of urothelial cancer.

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 laboratory services provided to the enrollee on April 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for immunization services provided to the enrollee on October
12, 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 the plan did not authorize any 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 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 immunization services provided to the enrollee on
October 12, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria 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 Prolia. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the review indicates that the enrollee is a 72-year-old female whose provider submitted an appeal for injection, Denosumab 1 mg. The Plan requires a trial of an oral bisphosphonate drug before they will approve the requested drug The reviewed documentation indicates that the member has been taking Fosamax weekly for years. There is a bone scan from January 19, 2022, but there is no comparison to see if the current medication regimen is failing or not. There are no listed side effects from the member taking Fosamax. There is no documentation provided indicating that this drug is less effective and/or has 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99326) provided on July 30, 2021 by an
out-of-network (OON) provider.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the out-of-network services were not pre-authorized.

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 services at issue in this appeal. The Plan did not pre-approve the service
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 physician services (99326) provided on July 30, 2021 by an out-ofnetwork
(OON) provider.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine (72148).  You asked the Plan to pre-approve an MRI scan of the lumbar spine. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules for the requested service have not been met because the medical guidelines recommend instead a computed tomography (CT) scan of the lumbar spine.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI scan of the lumbar spine. Our reviewer says that that the requested service is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee's compression fracture is indeterminate as to age and the enrollee reports no history of recent trauma. An MRI scan would be the more appropriate exam of choice allowing the evaluation of the various neural elements of the lumbar spine in an enrollee with chronic sciatica as well as the acute, subacute, or chronic nature of the L2 vertebral body based upon the T2 signal characteristics of the L2 level. The posterior elements of L2 will also be well evaluated by an MRI scan, thus assessing the stability of the fracture.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI scan of the lumbar spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) scan of the lumbar spine (72148).   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.