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

We decided that the Plan does not have to pre-approve Feraheme for the enrollee.

You asked the Plan to pre-approve Feraheme. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no indication their preferred drugs would likely be: less effective, and/or cause adverse effects for the member.

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 Feraheme. Our reviewer says that Feraheme is not medically reasonable and necessary. The Plan requires a trial of Infed and Venofer before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Feraheme. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) infectious agent detection by nucleic acid (DNA or RNA) severe acute respiratory syndrome coronavirus 2, amplified probe technique (87635) provided August 22, 2020
You asked the Plan to pay for the outpatient visit. You say that you believe there was an error in the denial. You would like to request review and reconsideration of this claim for payment. The Plan denied your request. The Plan says the claim was received past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the outpatient visit was not filed until December 02, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) infectious agent detection by nucleic acid (DNA or RNA) severe acute respiratory syndrome coronavirus 2, amplified probe technique (87635) provided August 22, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and prophylaxis (D1110) provided on September 9, 2021.
You asked the Plan to pay for the dental services. You say that your previous dentist retired. You say that you needed to establish care with a new dentist. You say that this dentist was not in network so the claim has to be submitted through medical services. You also say that the services should be covered in full. The Plan denied your request. The Plan says out of network providers may bill you for any amount greater than what the plan pays the provider. The Plan also says that this applies to services with $0 copayment.
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 and the services are listed as covered, out of network dentists may bill you for any amount greater than what the plan pays. The record shows that the Plan paid the allowed amount for the services in this case. The record also shows that the member liability was applied correctly. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and prophylaxis (D1110) provided on September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment the eye exam (92014) provided on May 24,
2021.
You asked the Plan to reduce the copayment the eye exam. You say that this was a routine eye exam and
should require only a $15 copayment, which you paid at the time of service. The Plan denied your request. The
Plan says this claim was processed correctly, and your copayment was assessed in accordance with your
contract. You are responsible for a $45 copayment for each Medicare-covered outpatient visit for services to
diagnose and/or treat diseases or conditions of the eye. The office visit in question was provided to address
cataracts, which are a medical (non-routine) issue.
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 each Medicare-covered outpatient visit for services to diagnose and/or treat diseases or
conditions of the eye.
You have been asked to pay a $45 copayment for the eye exam. Documentation shows that cataracts were
discussed during this exam, which means that the exam in question is medical and not routine. 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 reduce the copayment the eye exam (92014) provided on May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure
(CPAP) device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says the time frame after the trial has not been approved due to a lack of medical necessity.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the documentation shows that you are not using the device. There is no documentation that the
compliance issue is being addressed.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve continued use of a continuous positive airway pressure (CPAP) device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision services (92250, 92014) provided on October 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for out-of-network vision care. You say that these services were medically necessary, and you had authorization to see the enrollee in their home for this care. The Plan denied your request. The Plan says out-of-network care is only covered in certain limited circumstances. The services at issue were not urgent or emergent, nor were they pre-approved by the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue, and no documentation of any approval or referral was submitted for review. 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 vision services (92250, 92014) provided on October 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 9, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for specialty absorptive dressing, wound cover, sterile (A6252) alginate or other fiber gelling dressing (A6199) tape, non-waterproof (A4450) provided on September 24, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the wound care supplies. You say that the claim should have been paid and you request reconsideration of the denial. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  

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 specialty absorptive dressing, wound cover, sterile (A6252) alginate or other fiber gelling dressing (A6199) tape, non-waterproof (A4450) provided on September 24, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from November 11, 2020, to November 14, 2020.
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 DRG was updated in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC). 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 services at issue in this case were not supported by the medical records. Our physician reviewer found a review of the records has determined that the documentation supports DRG 606 - minor skin disorders with MCC, and not the billed DRG 871. While sepsis was documented in the history and physical, progress notes, and discharge summary, other medical record documentation was incomplete regarding this condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from November 11, 2020, to November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the electrical osteogenesis stimulator (E0747).
You asked the Plan to pre-approve the electrical osteogenesis stimulator. You say that you would like
reconsideration because the requested stimulator is medically necessary. The Plan denied your request. The
Plan says the clinical documentation provided and reviewed does not show that a nonunion of long bone
fracture exists.
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 electrical osteogenesis stimulator.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the documentation does not reveal nonunion of a long bone fracture
with radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment
with an osteogenesis stimulator. There is no evidence of a series of objective radiographic reports indicating
that healing has stopped between 2 sets of radiographs. There is no evidence on an objective formal
radiographic imaging study reports of the right ankle that there is failure of fusion of the joint. There is no
evidence of congenital pseudoarthrosis.
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 electrical osteogenesis stimulator have not been met. Therefore, we decided
that the Plan does not have to pre-approve the electrical osteogenesis stimulator (E0747).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for hearing aids provided on  June 14, 2021.  

You asked the Plan to pay an additional amount for the hearing aids. The Plan denied your request. The Plan says the Plan's hearing aid vendor processed the claim and applied the $1,250 per ear hearing aid benefit.  

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.   

We looked at the file and the Plan's rules. The file shows that the Plan paid the hearing aid benefit of $1,250. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on June 14, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional ultrasound (76536-59) provided on June 9, 2021.  

You asked the Plan to pay for an additional ultrasound. You say that two procedures were performed. The Plan denied your request. The Plan says a second procedure is not supported in the records.  

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  

We find that an additional unit of CPT code 76536 is not supported in the medical record. The medical record only supports 1 unit of CPT code 76536. Based on this information, we decided that Medicare rules for coverage of an additional ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for an additional ultrasound (76536-59) provided on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on October 13, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you needed to go to the dentist because you needed your tooth pulled. The Plan denied your request. The Plan says the benefit limit for D0140 has already been 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 limited oral evaluation per calendar year.   We looked at the file and Medicare rules. Evidence was provided to show that D0140 was provided on October 12, 2021. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation have already been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided by a participating provider on October 13, 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 this is medically necessary. The Plan denied your request. The Plan says this 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  The enrollee was admitted for hypotension and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0429, A0425) provided on August 10, 2021.  

You asked the Plan to waive the copayment for the ambulance transportation. You say that you heard this copayment could be waived if you could not be transported by any other means. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. A $250 copayment is required for each one-way Medicare-covered ambulance transport.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare covered ambulance transport.   

You have been asked to pay a $250 copayment for the ambulance transportation. There is no information in the contract regarding a copayment waiver if the services were medically necessary or if you could not be transported by other means. Generally, if services are not medically necessary, they are not covered, and you would be responsible for the full cost. 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 transportation services (A0429, A0425) provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 16,
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 a modifier was not billed on the claim to represent the services as separate/distinct.

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 imaging services provided to the enrollee on September 16,
2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus xT target gene panel provided on June 24, 2021, billed with 11 individual gene codes.
You asked the Plan to pay for the gene testing as billed. You say that this should be paid as this testing was medically necessary. The Plan denied your request. The Plan says there are several coding issues with this claim.
The Plan must follow Medicare rules. Medicare rules say that it is incorrect coding to bill for individual gene codes when a panel is ordered. The targeted panel code for the applicable number of genes tested should be used. Based on this information, we find that the billing of this 648 gene panel with individual gene codes is not appropriate. Therefore, we decided that the Plan does not have to pay for the Tempus xT target gene panel provided on June 24, 2021, billed with 11 individual gene codes.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on March 1, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says one code must be submitted for the panel.
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 looked at the file and the rules. The claim shows that the cancer gene panel was billed with multiple codes. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on March 1, 2021.