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

 We decided that the Plan does not have to pre-approve Evenity.  You asked the Plan to pre-approve Evenity. You say that this is medically necessary. The Plan denied your request. The Plan says that the drug is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Evenity. Our reviewer says that Evenity is not medically reasonable and necessary. Our physician reviewer found that your condition does not meet criteria for coverage of Evenity. Evenity is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. The requested use of Evenity is not FDA-approved for your diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig provided on October 28, 2020.
You asked the Plan to pay for the wig. You say that you would like the Plan to reconsider their denial of
payment. The Plan denied your request. The Plan says wigs are not covered under Medicare or the Plan.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are
ordered by a physician. The Plan follows these same rules.
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit
categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the
Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As
such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig provided on
October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cervical, multiple post collar (L0180) provided on March
23, 2021.
You asked the Plan to pay for code L0180. 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.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case.
The record shows that the Plan made several attempts to obtain the necessary documentation without success.
Therefore, we decided that the Plan does not have to pay for the Cervical, multiple post collar (L0180)
provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray exam (71046) provided on
September 24, 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 $35
copayment for basic radiological services provided in a specialist's office or urgent care center.
You have been asked to pay $31.10 for the basic radiological service provided in an urgent care center. This is
the Medicare allowed amount for this service which is less than the applicable copayment. 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 chest x-ray exam (71046) provided on September 24, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services (84165-26 and 86335-26) provided on May 12,
2021.
You asked the Plan to pay for codes 84165-26 and 86335-26. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says that this claim is a duplicate to
a claim that has already been processed and paid.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider did not bill
duplicate claims per Medicare guidelines. The claims have different billed amounts. Therefore, we decided that
the Plan has to pay for the laboratory services (84165-26 and 86335-26) provided on May 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided July 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 this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be
denied automatically as not medically necessary.
We looked at the file and Medicare rules. The code billed is not covered under Medicare rules. 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 (81455) provided July 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lifetime service plan for foot orthotics purchased on June 9,
2021.

You asked the Plan to pay for a lifetime service plan. You say that the service at issue is a necessity for your
care. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The lifetime service plan at issue in this appeal does not serve a purpose that is primarily medical in nature.
Therefore, we decided that the Plan does not have to pay for a lifetime service plan for foot orthotics purchased
on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Echocardiography (93308) provided on
August 30, 2021.
You asked the Plan to waive the copayment for the Echocardiography. 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 $125
copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.
You have been asked to pay a $113.06 copayment for an Echocardiography, which is less than the $125 states
in the Plan's contract. Echocardiography's fall 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 an Echocardiography
(93308) provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.

You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee is not insulin treated with multiple daily injections.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
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 your doctor insists that you need this inpatient
rehabilitation. The Plan denied your request. The Plan says this request is not medically necessary.
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 the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational
therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer
also found that there is not a reasonable expectation that you will be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an IRF.
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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  

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 the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as a skilled nursing facility.  

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D testing provided on July 1, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.

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 that the enrollee is an 82-year-old male with Barrett's esophagus without dysplasia following an EGD directed biopsy. WATS 3D testing improves sensitivity of screening for Barrett's esophagus, however, there is insufficient high quality evidence found in the literature showing this test leads to significantly improved overall outcomes (death, morbidity, etc.) compared to standard testing. Therefore, the WATS 3D test will not be considered not medically reasonable or necessary at this time. 

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 the WATS 3D testing provided on July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral x-ray (D0230) provided by an in-network
provider on September 8, 2021.
You asked the Plan to pay for an intraoral x-ray. You say that you believe this should be covered. The Plan
denied your request. The Plan says the benefit limit for intraoral x-rays has already been met and exhausted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one intraoral
x-ray per calendar year.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of an intraoral x-ray have already been met. Evidence was provided to show that more than one
intraoral x-ray was provided on September 8, 2021. Therefore, we decided that the Plan does not have to pay
for an intraoral x-ray (D0230) provided by an in-network provider on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office or other outpatient visit for the evaluation and
management of an established patient (99214) provided on June 22, 2021.
You asked the Plan to pay for office or other outpatient visit. You say that you would like this claim
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has
not been billed in accordance with Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that payment for an additional unit of CPT code 99214 is not supported in the medical record.
Specifically, the record indicates that the Plan has processed and paid for another evaluation and management
service which was rendered and billed by the same physician. If more than one evaluation and management
service is provided on the same day to the same enrollee by the same physician, only one evaluation and
management service may be reported. Based on this information, we decided that Medicare rules for coverage
of office or other outpatient visit have not been met. Therefore, we decided that the Plan does not have to pay
for office or other outpatient visit for the evaluation and management of an established patient (99214)
provided on June 22, 2021.
Appeal type: Home Health
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 all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period. HHAs receive a single payment for a 30-day period of care after the final claim is submitted. You can find this information in 42 CFR 484.205 (g) (3).
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.
Explanation of decision
We decided that the Plan does not have to pay for the home health services provided from February 22, 2021, to March 19, 2021.
You asked the Plan to pay for the home health services. You say that the Request for Anticipated Payments (RAP) claim was originally billed to Medicare. You also say that it was rejected as the enrollee was active with the Health Plan. The Plan denied your request. The Plan says the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set at 0 percent at the beginning of every 30-day period. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Specifically, the file shows that the RAP claim was
not submitted within 5 calendar days after the "from date". Therefore, we decided that the Plan does not have to pay for the home health services provided from February 22, 2021, to March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81263, 81450, 88341, 88342) provided June 29,
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 the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 81263, 81450, 88341, & 88342 are not supported in the medical record. Specifically,
required modifiers (59) to show distinct and separate services were not billed for the lab codes. 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 (81263, 81450, 88341, 88342) provided June 29,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-therapeutic Dexcom CGM and supplies (CPT code(s): A9276, A9277, and A9278).
You asked the Plan to pre-approve the items. You say that the primary care physician did not add information that you take the insulin three (3) times a day. You state you have been using the Dexcom G6 for years and want to continue using it. The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The Plan contacted the ordering provider to submit a new referral or wish to change the CGM codes to the K CPT codes (therapeutic CGM codes and they are covered by Medicare) but they declined because all the pharmacy contracted with medical group only accepts A codes. The codes submitted by the provider are not covered by Medicare or the health plan. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve non-therapeutic Dexcom CGM and supplies (CPT code(s): A9276, A9277, and A9278).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on June 24, 2021.
You asked the Plan to pay for the ConfirmMDx testing. 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.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. Medicare only covers ConfirmMDx for males who have undergone a
previous cancer-negative prostate biopsy. The file does not show result of prior prostate biopsy. Based on this
information, we decided that Medicare rules for coverage of the ConfirmMDx testing have not been met.
Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on June 24,
2021.