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

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 7,
2021.

You asked the Plan to pay for the services. You say that the level of service was supported. The Plan denied
your request. The Plan says this should not be unbundled.

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 72114
is a column II code to column I code 72082. 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 October 7, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for paramedic intercept provided on December 20, 2020.  You asked the Plan to pay for paramedic intercept. The Plan denied your request. The Plan says the paramedic services did not occur in a rural area.  The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York.  The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for paramedic intercept provided on December 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (88120) provided January 26, 2021.

You asked the Plan to pay for the genetic testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that bladder cancer tumor markers performed by any technology immunoassay, molecular, or FISH testing, are not covered for screening of all patients with hematuria. 

We looked at the file and Medicare rules. This test is not covered for the enrollee's diagnosis without prior diagnostic studies being performed. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (88120) provided January 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on June 30, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.  The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination.   The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80053, 82728, 83540, 83970, 84100, 84466, 84520, 85014, 85018, 85027, 87340) provided February 1, 2021 to February 22, 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 codes 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.  We find that CPT codes 80053, 82728, 83540, 83970, 84100, 84466, 84520, 85014, 85018, 85027, & 87340 are not supported in the medical record. Specifically, the records do not show these tests are unrelated to End Stage Renal Disease treatment. These lab services are included in the Dialysis services billed and cannot be billed seperately. 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 (80053, 82728, 83540, 83970, 84100, 84466, 84520, 85014, 85018, 85027, 87340) provided February 1, 2021 to February 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services provided to the enrollee on July 27, 2021.
You asked the Plan to pay for the services. You say that air transport was hailed due to the distance of the requested facility. The Plan denied your request. The Plan says the ambulance service must meet all program coverage criteria in order for payment to be made.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 that in this case, the record indicates that the enrollee had abdominal pain and requested transfer to a further facility rather than one within ground transportation range. The record provided does not indicate that the nearer hospital was not able to provide the appropriate care. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided to the enrollee on July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lumigan.  You asked the Plan to pre-approve Lumigan. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B benefit.  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 Lumigan.     Benefits for Lumigan 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injections (62320) provided August 30, 2021.  You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says the records do not support the billed services.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. No clinical records were submitted to support the billed services. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided August 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve outpatient speech therapy to be provided by the requested out-of-network provider.  You asked the Plan to pre-approve outpatient speech therapy to be provided by the requested out-of-network provider. The Plan denied your request. The Plan says these services can be provided in-network.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient speech therapy to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve power wheelchair options.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your upper limb strength and function are adequate to control the approved options with their own switches, and your trunk and shoulders are within functional limits.  The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered under certain medical indications.  The file shows that an expandable control system and custom fabricated back cushion was requested. 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 requested services. Our physician reviewer found that you have a history of paraplegia and require a power wheelchair for mobility. The provided records document that you have 3-/5 to 3/5 upper extremity strength. You are independent with feeding, bathing, grooming and dressing, thus indicating you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches. There is no documentation that the enrollee meets the coverage criteria for the requested custom cushion. The provided records from the treating provider do not document any deformity or condition for which the requested custom cushion would be necessary.  The file shows that a seat elevation system was requested. This feature is non covered because it is not primarily medical in nature. We looked at the physician's review, the file, and Medicare rules. 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 pre-approve power wheelchair options.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit provided on April 29, 2021.  You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered as part of a follow-up. 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 $50 copayment for Outpatient hospital services.       You have been asked to pay a $50 copayment for a specialist office visit. Based on your contract with the Plan these services are ineligible to be covered in full as they were performed after the 90-day global period. Specialist office visit falls within the Outpatient hospital 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 copayment for a specialist office visit provided on April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 19, 2021.  You asked the Plan to pay for the laboratory services. 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 a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.    We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regard to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve inpatient psychiatric care from February 3, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 3, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says that the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the record clearly indicates that the Plan utilized medical records to make their decision. The Plan has not forwarded any medical records for review. Please note, we requested these records from the Plan and did not receive a response. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric care from February 3, 2022, forward.   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 waive the coinsurance for an outpatient surgery provided on September 20, 2021.  You asked the Plan to waive the coinsurance for the outpatient surgery. You say that the services should be considered inpatient The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Outpatient Hospital Observation.       You have been asked to pay a 20% coinsurance for outpatient surgery (allowed amount is $13,178.86 x 20% = $2,635.77). Outpatient surgeries fall within the Outpatient Hospital Observation 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 coinsurance for an outpatient surgery provided on September 20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).
You asked the Plan to pre-approve Injectafer. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injectafer. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that clinical records do not support a medically necessary exception to the Plan formulary to warrant approval of non-preferred Injectafer for the enrollee 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 Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Injectafer (J1439).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Injectafer solution.  You asked the Plan to pre-approve Injectafer solution. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.    Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Injectafer solution. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has iron deficiency anemia and is intolerant to oral iron replacement. The documentation does not support that the enrollee has tried and failed Ferrlecit (sodium ferric gluconate), Infed or Venofer. The documentation does not include an indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer solution have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer solution.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Repatha.  You asked the Plan to pre-approve Repatha. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.  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 Repatha.   Benefits for Repatha 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation services provided on September 24, 2021.  You asked the Plan to waive the copayment for the ambulance transportation services. You say that the services are too expensive and will cause financial hardship. 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 $300 copayment for Ambulance services. You have been asked to pay a $300 copayment for ambulance transportation services. 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 ambulance transportation services provided on September 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office visit (99215) and anesthetic agents and/or steroid injections of the greater occipital nerve and the peripheral nerve (64405, 64550) to be provided by an out-of-network (OON) provider.   You asked the Plan to pre-approve an office visit and anesthetic agents and/or steroid injections of the greater occipital nerve and the peripheral nerve. You say that you need the service as you have been in pain for over a year and the current provider has not been able to assist. The Plan denied your request. The Plan says the provider you wish to see is out-of-network and there are in-network providers available.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99215) and anesthetic agents and/or steroid injections of the greater occipital nerve and the peripheral nerve (64405, 64550) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tier exception (a higher cost drug at a lower cost level) for Ipratropium Bromide.  You asked the Plan to pre-approve a tier exception for Ipratropium Bromide. You say that you would like a tiering exception for this medication. The Plan denied your request. The Plan says a tier exception is only available for Part D drugs.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Ipratropium Bromide have not been met. The requested drug falls within the Part B drug category. A tier exception can only be issued for Part D drugs. Therefore, we decided that the Plan does not have to pre-approve a tier exception (a higher cost drug at a lower cost level) for Ipratropium Bromide.