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

We decided that the Plan does not have to pre-approve the Vertiflex superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing provided on July 2, 2021.
You asked the Plan to pay for GeneSight testing. You say that no basis exists for the Plan to deny coverage of
this testing. The Plan denied your request. The Plan says the denial of payment for this testing is correct,
because this test is not covered by Medicare, was not billed correctly, and there is no signed physician order for
this testing.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Specifically, the order form submitted
is unsigned. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have
not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing provided on July
2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) provided June 4, 2021.
You asked the Plan to pay for the gingival irrigation. You say that the Plan's customer service representative did not advise you that gingival irrigation is not covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation - per quadrant (D4921) provided June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection (J7312) provided September
27, 2021.
You asked the Plan to waive the copayment for the injection. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 20%
coinsurance for Part B drugs.
You have been asked to pay a 20% coinsurance ($280.10) for the injection. The injection falls within the Part B
drugs 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 injection (J7312) provided
September 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for open procedures involving hip joint (01214) provided on September 4, 2021.
You asked the Plan to pay for the anesthesia. You say that this date of service is after the termination of the enrollee's Hospice period. You also say that you would like this claim to be reprocessed for benefits. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 3, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the anesthesia for open procedures involving hip joint (01214) provided on September 4, 2021
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Zirabev.  You asked the Plan to pre-approve Zirabev. You say that data supports the safety and efficacy of pembrolizumab in combination with Zirabev. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Zirabev has not shown benefit in the enrollee's clinical circumstances.  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 Zirabev. Our reviewer says that the enrollee does not meet the Medicare criteria for Zirabev. Our physician reviewer found the requested use of Zirabev is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. There is insufficient support in major drug compendia or in clinical research appearing in a Medicare-approved medical journal for the requested use of Zirabev.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zirabev have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Zirabev.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the at-home fitness equipment purchased on September 16, 2020.  You asked the Plan to pay for the fitness equipment. You say that these services have been beneficial for you and saved other costs for the Plan. The Plan denied your request. The Plan says wellness benefit reimbursement requests for 2020 must be received by the Plan no later than March 31, 2021. This request was received after this date.  The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan provides reimbursement for eligible wellness services provided in 2020 when the requests for reimbursement are received no later than March 31, 2021.  The Plan's rules for coverage of gym benefits have not been met because this request was not submitted until August 2021. Therefore, we decided that the Plan does not have to pay for the at-home fitness equipment purchased on September 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound of the head and neck provided on June 15, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you were supposed to have a biopsy done but the doctor ordered the wrong test. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $100 copayment for diagnostic radiology services in an outpatient hospital facility.  You have been asked to pay a $100 copayment for the ultrasound. Please note that while it may not have been the correct test needed, the service was still performed. 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 an ultrasound of the head and neck provided on June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the subcutaneous tissue debridement (11042) rendered by the out-of-network (OON) provider on June 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 or a referral from a primary care physician.
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, nor was a referral submitted from a primary care physician. 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 subcutaneous tissue debridement (11042) rendered by the out-of-network (OON) provider on June 28, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says your records do not show that you require daily skilled services that can only be
provided on an inpatient basis. The Plan states the services you require, such as additional therapy services, can
safely be received at a different setting, for example, home with home health, in residential care, or home with
close follow-up with your doctor.
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 there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a SNF setting.
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 SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) coded 78830 provided on August 17, 2021.

You asked the Plan to pay for the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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 78830 is a column II code to column I code 79445. 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 the radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) coded 78830 provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug test (G0481) rendered by the out-of-network (OON) provider on June 10, 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 drug test (G0481) rendered by the out-of-network (OON) provider on June 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport
(A0998) provided on June 2, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you did
not request the ambulance services. The Plan denied your request. The Plan says the ambulance benefit is a
transport benefit and if there is no transport then there is no Medicare-covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on June 2, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no
transport (A0998) provided on June 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 5, 2021.
You asked the Plan to waive the copayment for the laboratory services. You say that you already paid a copayment for the office visit you should not have to make another copayment. The Plan denied your request. The Plan says the proper copayment was applied for this service.
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 $10 copayment per day, per provider, for Medicare-covered lab services.
You have been asked to pay a $10 copayment for the laboratory services. Laboratory services 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 laboratory services provided on August 5, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for prostate specific antigen (PSA) screening services provided
to the enrollee on April 20, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated that the diagnosis reported was R97.20 for elevated prostate specific antigen
(PSA). There is no documentation of elevated PSA, interval change, or prostate disease.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests
are not covered. There is no medical record documentation to show this testing was ordered to determine
treatment of confirmed disease. The test at issue in this appeal was requested for screening purposes. Medicare
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for prostate specific antigen (PSA) screening services provided to the enrollee on April 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has mild chronic
abdominal pain without fever, chills, or shortness of breath. She is noted to not be in any distress and has
subjectively tender abdomen, mild pitting edema, and otherwise generalized weakness at her baseline. There is
no evidence of a red flag condition or progression of symptoms suggesting a need for the requested CT scan.
There was no record of other less invasive testing methods to identify the cause of her mild abdominal
discomfort or record of failed conservative treatments for this symptom to justify CT at this time. Therefore,
CT abdomen with contrast will be considered not medically necessary at this time based on the provided
documentation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a computed tomography (CT) scan of the abdomen.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve HHA services (CPT code G0156 x 10).
You asked the Plan to pre-approve the services. You say that you are severely disabled, and your husband works all day. You state you need someone to help you when he is away. The Plan denied your request. The Plan says your records show that you have caregiver(s) who help with your daily living activities which include bathing, dressing, toileting, grooming, cleaning, and meal preparation. The Plan states this information does not support the need for a home health aide to make visits and if you have a change in your condition, your doctor can submit a request that includes information supporting the medical necessity for home health aides.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 services. Our physician reviewer found the records do not show that skilled nursing services are currently required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance
program to maintain your condition and/or prevent deterioration. The records do not show that skilled therapy services are currently required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. The documentation does not reveal that skilled services are needed. Without skilled services the request for home health aide is not medically necessary. The services do not meet the definition of home health aide services as per Section 50.2 and home health aide services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 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 pre-approve HHA services (CPT code G0156 x 10).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your
request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Ondansetron for the
enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.