Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services coded S5501 provided on January 1, 2021.
You asked the Plan to pay for the home infusion therapy 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 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, the CPT Code Manual definition of code S5501 is home infusion therapy, catheter care / maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S5501 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services coded S5501 provided on January 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit. 
 
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan 
denied your request. The Plan says the enrollee must try and fail Retacrit first. 
 
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 Procrit. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the documentation 
provided, the enrollee is noted to have anemia associated with chronic kidney disease.  A request has been 
made for Procrit to treat the anemia.  The health plan requires that Retacrit be used.  There is no evidence that 
the enrollee is allergic to or intolerant of Retacrit.  There is no evidence that the enrollee has tried and not 
responded to Retacrit.  There is no documentation as to why Retacrit would not be expected to be safe and 
effective for the enrollee.  Therefore, the requested Procrit is not shown to be currently medically necessary and 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Procrit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Procrit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the ferric carboxymaltose injection and intravenous infusion provided on May 24, 2021.
You asked the Plan to waive the cost for the ferric carboxymaltose injection and intravenous infusion. You say that this is too expensive, and you want to appeal. The Plan denied your request. The Plan says the cost share applied correctly.
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 20% coinsurance for Medicare-covered Part B prescription drugs and a $250 copayment per visit for Medicare-covered surgical, IV therapy and blood transfusion services from an in-network provider.
You have been asked to pay $401.94 for the ferric carboxymaltose injection and intravenous infusion.
Service
Allowed Amount
Standard Cost
Member Liability
Ferric Carboxymaltose Injection
$759.72
20%
$151.94
Intravenous Infusion
$1,009.72
$250
$250
TOTAL:
$401.94
The ferric carboxymaltose injection falls within the "Medicare Part B prescription drugs" benefit category. The intravenous infusion 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 cost for the ferric carboxymaltose injection and intravenous infusion provided on May 24, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 3, 2021 by an out-of-network provider.

You asked the Plan to pay for the office visit (99202). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were not urgent, emergent nor 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 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 the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on February 3, 2021 by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography, lower extremity (73700) provided
February 22, 2021.

You asked the Plan to pay for the diagnostic service. You say that you are being billed for various services and
or treatments that you have already paid for. You feel that these should have been covered under your current
plan. The Plan denied your request. The Plan says the claim had processed correctly per the Evidence of
Coverage. The records show that $438.96 had been applied to the deductible prior to processing of this claim.
This left a remaining deductible amount of $261.04.

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 there is $750 deductible which applies to Outpatient diagnostic tests,
radiological diagnostic services, not including x-rays. Until you have paid the deductible amount, you must pay
the full cost of your covered services.

The item or service you asked the Plan to pay for falls within the benefit category Outpatient diagnostic tests,
radiological diagnostic services, not including x-rays.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which
applies to Outpatient diagnostic tests, radiological diagnostic services, not including x-rays. This cost sharing is
a contractual obligation that had not been met at the time the diagnostic service was received on February 22,
2021. Therefore, we decided that the Plan does not have to pay for the computed tomography, lower extremity
(73700) provided February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88341, 88312, 88342, 88305) provided
on March 25, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this was the only available pathologist.
The Plan denied your request. The Plan says in-network providers could have provided these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for laboratory services (88341, 88312, 88342, 88305)
provided on March 25, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the thoracic spine (72146)
provided on April 22, 2021.

You asked the Plan to waive the copayment for an MRI scan of the thoracic spine. You say that the charge at
issue is unfair to people on a fixed government pension. The Plan denied your request. The Plan says the
correct copayment 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 $350
copayment for diagnostic radiology other than CT scans.

You have been asked to pay a $350 copayment for an MRI scan of the thoracic spine. An MRI scan of the
thoracic spine 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 MRI scan of the thoracic spine (72146)
provided on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve an MRI. You say that the results of the previous MRI were not properly
reviewed. The Plan denied your request. The Plan says additional tests are not needed to direct care.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our physician reviewer found
that you have ongoing complaints of back pain. An MRI of the thoracic spine was requested. The reviewed
medical records indicates that you had a similar test done previously. The prior study showed what was needed
to be seen in order to treat your condition. There is no provided clinical rationale to support repeat imaging at
this time. The results of prior imaging do not show a clear reason for additional testing. The review has
determined that the requested MRI is not medically reasonable or 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 an MRI have not been met. Therefore, we decided that the Plan does not have to
pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27130) provided June 3, 2021.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the provider on the claim is not a valid billing provider.

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 code 27130 is not supported in the medical record. Specifically, Provider taxonomy
174400000X is listed on the claim form. This taxonomy is invalid for billing purposes. Based on this
information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore,
we decided that the Plan does not have to pay for surgical services (27130) provided June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology consultation during surgery services coded
88331 provided on May 25, 2021.
You asked the Plan to pay for the pathology consultation during surgery 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.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88331
for the pathology consultation during surgery services has a bundled relationship with code 17311 and cannot
be paid as billed. This code cannot be paid as a separate line item. 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 pathology
consultation during surgery services coded 88331 provided on May 25, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for opioid treatment services (G2067) provided on May 1, 2021.

You asked the Plan to pay for the opioid treatment services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the service 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 opioid treatment services (G2067) provided on May 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit provided on May 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records which show the necessity of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office visit provided on May 18, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the ankle orthosis (L1902) provided on May 4, 2021.
You asked the Plan to pay for the ankle orthosis. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the ankle orthosis by a contract provider. The file does not show that the Plan provided
notice that the ankle orthosis would not be covered. Under Medicare rules, this means the ankle orthosis is
considered approved by the Plan. Therefore, we decided that the Plan has to pay for the ankle orthosis (L1902)
provided on May 4, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).

You asked the Plan to pre-approve the requested CGM. You say that you have been using the Freestyle Libre which does not stay attached. You feel that the Dexcom brand is necessary due to this issue. The Plan denied your request. The Plan says review of the records show that you do not meet the criteria for coverage of a CGM since you are not using insulin at least three times per day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily administrations. The documentation indicates that you take only one dose of Lantus insulin at night. Based on this information, we decided that Medicare rules for coverage of the requested CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 rendered on April 20, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on January 14, 2021.
You asked the Plan to pay for drug testing. You say that physician send specimens to your lab for testing and you do not have any access to physician notes or reports. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The documentation submitted shows that the sample for this testing was taken in an office setting, therefore the POS code 81 - indicating an independent lab setting - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on January 14, 2021