Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on October 1, 2021.  You asked the Plan to pay for physician's services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.  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 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 physician's services provided on October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap booster vaccine received on October 18, 2021.
You asked the Plan to pay for the services. You say that you weren't asked for permission to get this vaccine. The Plan denied your request. The Plan says this is not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Therefore, we decided that the Plan does not have to pay for the Tdap booster vaccine received on October 18, 2021.
Benefits for the services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483, 80307) rendered by the
out-of-network (OON) provider on September 28, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 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 drug testing services (G0483, 80307) rendered by the out-of-network (OON)
provider on September 28, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to reduce the copayment for port removal provided on October 11, 2021.
You asked the Plan to reduce the copayment for port removal. You say that the Plan's coverage document show
you should only be responsible for a $225 copayment. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $225 copayment for ambulatory surgical services.
The record shows the service you received is an ambulatory surgical service. The EOC says the $225
copayment applies to ambulatory surgical services, but it does not clearly say that the services must take place
in an ambulatory surgical center in order for the $225 copayment to apply. The Plan says you must pay a $300
copayment for port removal. Based on the Plan contract, however, you cannot be asked to pay more than a
$225 copayment for port removal. Therefore, we decided that the Plan has to reduce the copayment for port
removal provided on October 11, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis (L3960) provided on August 24, 2021.
You asked the Plan to pay for the shoulder orthosis. You say that the item was medically necessary. The Plan
denied your request. The Plan says evidence indicates this service was related to a prohibited telemarketing
contact.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of the shoulder
orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis
(L3960) provided on August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee is currently unstable for transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that the enrollee presented to the acute care hospital with shortness of breath. She tested
positive for the coronavirus. Her hospital course was complicated congestive heart failure, urinary tract
infection, and malnutrition. She is receiving appropriate care at the present acute care hospital. She does not
require services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the enrollee has not
tried and failed Infed and Venofer.
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 physician reviewer found that the enrollee has a history of iron deficiency anemia. The Plan requires a trial of Infed and Venofer before they will approve the requested drug. In this case, the enrollee 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 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 21, 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 follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal was requested solely 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 the laboratory
services provided on June 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for self-administered drugs received from July 19, 2021, to July
21, 2021.
You asked the Plan to pay for the drugs. You say that this is medically necessary. The Plan denied your
request. The Plan says this 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 pay for self-administered drugs received
from July 19, 2021, to July 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 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 service is not 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 76705 is a column II code to column I code 93976. 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 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device (E0651), provided on
June 8, 2021..
You asked the Plan to pay for intermittent limb compression device. You say that the item is medically
necessary. The Plan denied your request. The Plan says the item is not medically necessary.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
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 intermittent limb compression device. Our
reviewer says that you do not need this medical item. Our physician reviewer found there is no documentation
of the persistence of chronic and severe lymphedema as identified by the documented presence of at least one
of the following clinical findings: marked hyperkeratosis with hyperplasia and hyperpigmentation,
papillomatosis cutis lymphostatica, deformity of elephantiasis or skin breakdown with persisting lymphorrhea.
Additionally, the physical examination included in the records does not support the presence of ulcers.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of intermittent limb compression device have not been met. Therefore, we decided
that the Plan does not have to pay for intermittent limb compression device (E0651), provided on June 8, 2021..
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for remote cardiac monitoring on May 18, 2021.
You asked the Plan to waive the copayment for remote cardiac monitoring. You say that you have never been
charged in the past and disagree with the charges. The Plan denied your request. The Plan says that 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. Your
contract with the Plan says that enrollees must pay a $0 copayment for diagnostic tests and procedures.
The Plan says you must pay a $35.18 copayment for remote cardiac monitoring. Remote cardiac monitoring
falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Based on
the Plan contract, however, you cannot be asked to pay more than a $0 copayment for remote cardiac
monitoring. Therefore, we decided that the Plan has to waive the copayment for remote cardiac monitoring on
May 18, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection.
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that this procedure is medically
reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been
met at as there is no indication member is in active rehabilitation program and no evidence of 50% sustained
improvement.
The Plan follows Medicare rules. Medicare rules say that a repeat ESI is subject to the criteria listed 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 a repeat epidural steroid injection. Our
reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer
found that the enrollee is a 72 year old male with chronic low back pain with radiculopathy due to lumbar
stenosis. He is status post L4-L5 lumbar interbody fusion and status post transforaminal epidural steroid
injection (TFESI) on October 19, 2021, with 40% pain relief and more function, and status post TFESI on
08/31/21 with 90% pain relief The enrollee has had physical therapy per his primary care physician, is in an active home exercise program,
and has taken Gabapentin and Tylenol. Magnetic resonance imaging shows moderate left L5-S1 foraminal
stenosis. As outlined in the Local Coverage Determination, there is no documentation of at least 50% of
sustained improvement in pain relief and/or improvement of function measured from baseline using SAME
scale for at least three (3) months. In addition, it is unclear if the enrollee is in an active physical
therapy/rehabilitation program. The review has determined that the member does not meet the coverage criteria
for the requested 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 a repeat epidural steroid injection have not been met. Therefore, we decided that
the Plan does not have to pre-approve a repeat epidural steroid injection
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and Infection control supplies (S8301) provided on September 21, 2021.

You asked the Plan to pay for codes S1015 and S8301. 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 as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We looked at the file and Medicare rules. In this case, CPT codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services.

Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and Infection control supplies (S8301) provided on September 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on October 9, 2021.
You asked the Plan to pay for code 70450. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 the Computed tomography (CT) scan (70450) provided on October 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total abdominal hysterectomy (58150).
You asked the Plan to pre-approve a total abdominal hysterectomy. You say that this is medically necessary. The Plan denied your request. The Plan says the requested hysterectomy services are not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a total abdominal hysterectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has menorrhagia and uterine fibroids. The records provided are insufficient to determine medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a total abdominal hysterectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a total abdominal hysterectomy (58150).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and
management of an established patient (99336) rendered by the out-of-network (OON) provider on July 29,
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 domiciliary or rest home visit for the evaluation and management of an established
patient (99336) rendered by the out-of-network (OON) provider on July 29, 2021
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to waive the copayment for remote cardiac monitoring provided on September 21, 2021.

You asked the Plan to waive the copayment for remote cardiac monitoring. You say that that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $0 copayment for diagnostic tests and procedures. 

The Plan says you must pay a $35.18 copayment for remote cardiac monitoring. Remote cardiac monitoring falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for remote cardiac monitoring. Therefore, we decided that the Plan has to waive the copayment for remote cardiac monitoring provided on September 21, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide.
You asked the Plan to pay for a stair glide. You say that the item is medically necessary. The Plan denied your
request. The Plan says this is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they
are not primarily medical in nature.
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pay for a stair glide.