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

 We decided that the Plan does not have to pre-approve palonosetron.  You asked the Plan to pre-approve palonosetron. You say that this is medically necessary. The Plan denied your request. The Plan says this is not supported.  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 palonosetron. Our reviewer says that the requested use of palonosetron is not supported. Our physician reviewer found the record indicates that the enrollee has a diagnosis of adenocarcinoma of the lung. The enrollee is receiving low risk emetogenic chemotherapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of palonosetron have not been met. Therefore, we decided that the Plan does not have to pre-approve palonosetron.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hearing aids (V5261) purchased on August 30, 2021.  

You asked the Plan to pay for the hearing aids. You say that the provider told you that you would be covered for hearing aids up to $1,000 every three years, and you made this purchase because you understood that the Plan would be providing financial aid for these services. The Plan denied your request. The Plan says these hearing aids were purchased from a provider outside of the Plan's specified hearing vendor network. Hearing aids ordered through providers who do not participate in the specified network are not covered.  

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. The Plan pays for hearing aids only when they are purchased through the Plan's specified hearing vendor network.   

We looked at the file and the Plan's rules. The provider in this case does not participate in the Plan's routine hearing vendor network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5261) purchased on August 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction (92015) provided on October 19, 2021.  You asked the Plan to pay for the eye refraction. You say that you went to a network provider and did not know this was a medical service and would not be covered. The Plan denied your request. The Plan says the eye exam on the date in question was a medical (non-routine) vision exam for age-related nuclear cataracts, bilateral and hypermetropia. Eye refractions are only covered when provided in conjunction with a routine (non-medical) eye exam and are received from a provider in the Plan's routine vision network.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are performed as part of a routine eye exam by a provider in the Plan's specified routine vision network.  We looked at the file and the Plan's rules. The eye exam in this case was billed with medical diagnoses and therefore is not a routine exam. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xiidra solution 5%.  You asked the Plan to pre-approve Xiidra solution. You say that Xiidra has been working for the enrollee. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xiidra solution 5%.   Benefits for Xiidra solution may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve psychotherapy services (90837).  

You asked the Plan to pre-approve psychotherapy services. You say that these services have been performed in the past and remain medically necessary. The Plan denied your request. The Plan says the provider in question is not a Medicare-certified provider.  

The Plan must follow Medicare rules. Medicare rules say that mental health services are covered when rendered by a provider type listed in the Medicare rules section.   

We looked at the file and Medicare rules. In this case, the provider in question is a Licensed Mental Health Counselor (LMHC) which is not among the types of health professionals that Medicare covers. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services (90837).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography coded 70544 provided on September 6, 2021.  You asked the Plan to pay for the magnetic resonance angiography. 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 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography coded 70544 provided on September 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance services provided to the enrollee on August 10, 2021.  You asked the Plan to pay for the services. You say that the Plan denied your request. The Plan says the claim is being disallowed due to an invalid or missing diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate secondary diagnosis code for ambulance services.  We find that CPT codes A0425 and A0429 is not supported in the medical record. Specifically, these codes require very specific secondary diagnosis codes to qualify for payment. R42 is not one of the four covered secondary diagnosis codes. 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 ambulance services provided to the enrollee on August 10, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.  You asked the Plan to pre-approve CT scan. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this scan is 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 CT scan. Our reviewer says that you meet the Medicare criteria for this CT scan. Our physician reviewer found there is documentation of persistent symptoms in you that are not explained by physical examination or upper endoscopy. CT scans of the brain and of the abdomen/pelvis would be medically reasonable and necessary to arrive at a diagnosis and potential treatment options for you.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Potassium Chloride ER 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 self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Potassium Chloride ER 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.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 12 outpatient physical therapy (PT) visits.  You asked the Plan to pre-approve the 12 PT visits. The Plan denied your request. The Plan says there is no evidence that physical therapy is medically necessary to treat the enrollee's condition.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 12 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the patient's condition. Our reviewer found that the records do not demonstrate that the unique skills of a professional therapist are required to provide treatment safely and effectively, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. Our physician reviewer also found that the requested services are not part of a maintenance program, are not the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  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 12 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 outpatient physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy services coded 45384 provided on August 2,
2021.
You asked the Plan to pay for the colonoscopy services. 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. The
rules also state that providers may bill services with a -59 modifier if the service billed with the modifier
indicates a distinct procedural service.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 45384
is a column II code to column I code 45385. This claim has not been billed with an appropriate modifier to
bypass the edit. In addition, this code was billed with the -59 modifier. However, the medical records provided
do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, codes
45385 and 45384 are within the same family as demonstrated by indicator "3". This means these codes are not
separately payable. Based on this information, we decided that Medicare rules for coverage of services billed
with a -59 modifier have not been met. 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 colonoscopy services coded 45384
provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit and comprehensive hearing exam provided on January 14, 2021.
You asked the Plan to waive the copayments for the specialist office visit and hearing exam. You say that you feel that you are being double charged for the hearing exam as you have already paid your $40 copayment. 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 $40
copayment for each specialist office visit. Your contract with the Plan also clearly says that you must pay a $40 copayment for each hearing exam to determine if you need treatment for a hearing condition. You have been asked to pay a $40 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. You have also been asked to pay a $40 copayment for the hearing exam. The hearing exam falls within the Hearing Services 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 copayments for a specialist office visit and comprehensive hearing exam provided on January 14, 2021
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pre-approve the JAK2 testing. We decided that the Plan does not have to pre-approve the F5 and F2 testing.

You asked the Plan to pre-approve the JAK2, F2 and F5 testing. You say that you would like reconsideration based on the records submitted. The Plan says that the requested laboratory testing is not medically necessary.

We decided that the Plan has to pre-approve the JAK2 testing.

The Plan follows Medicare rules. Medicare rules say that genetic testing of JAK2 exon 12, performed to identify PV, is medically necessary when genetic testing impacts medical management, when the patient would meet World Health Organization's diagnostic criteria for PV, if JAK2 exon 12 testing were positive and when JAK2 V617F mutation analysis was previously completed and was negative. 

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 JAK2 testing. Our reviewer says that this member does meet crtieria for testing for polycythemia with JAK2 given Hb >16.5 and thrombosis. JAK2 is reasonable and medically necessary. 

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 JAK2 testing have been met. Therefore, we decided that the Plan has to pre-approve the JAK2 testing.

We also decided that the Plan does not have to pre-approve the F5 and F2 testing.

The Plan follows Medicare rules. Medicare rules say that Medicare may consider coverage for FVL and/or F2 genetic testing in unusual circumstances where testing will change clinical management of the patient. 

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 F5 and F2 testing. Our physician reviewer found factor V Leiden and prothrombin gene mutation are not necessary as these are unlikely to change management should they be positive. F5 and F2 genetic testing are not reasonable or medically necessary. 

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 F5 and F2 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve the F5 and F2 testing.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.
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 vertilfex spacer 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 insertion of Vertiflex Superion device for the enrollee
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the home health services (S9122) provided form August 2, 2021, to August 4, 2021.  You asked the Plan to reimburse you for the home health services. You say that this provider has not opted out of Medicare. The Plan denied your request. The Plan says payment cannot be made for service received from a provider who is not certified by Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.    Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for the home health services (S9122) provided form August 2, 2021, to August 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab (J9299).
You asked the Plan to pre-approve Nivolumab. The Plan denied your request. The Plan says Nivolumab
(J9299) is not supported to be for a medically accepted use in this case.
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 Nivolumab. Our reviewer says that
Nivolumab (J9299) is not medically reasonable and necessary for the enrollee. Our physician reviewer found
the requested use of Nivolumab (J9299) is not FDA-approved for the enrollee's diagnosis. Our reviewer found
that the use is not supported by one of the major drug compendia or by clinical research that appears in a
Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also
found that the use is not listed as not indicated, not supported or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Nivolumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve Nivolumab (J9299).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye refraction services provided on September 27, 2021.  You asked the Plan to pay for the services provided. You say that you cannot cover the cost. The Plan denied your request. The Plan says eye refractions are only covered when performed as a routine screening.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.   The file shows that you received a medical eye exam on the date of service at issue. You also received eye refractions services. Refractions are only covered by your Plan when received during a routine eye exam. Based on this information, we decided that the rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction services provided on September 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 13, 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 provider did not bill as required by 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. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. 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 13, 2021.