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

We decided that the Plan does not have to pay for the anesthesia services provided on April 9, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.
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 99100 is Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. This code cannot be paid as a separate line item. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on April 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on April 11, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim should be submitted to Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on April 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that this request is medically necessary. The Plan denied your request. The Plan says step therapy criteria 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 Aranesp. Our reviewer says that the
requested drug is not medically necessary. Our physician reviewer found the enrollee is an 87-year-old with
anemia of chronic kidney disease and Aranesp has been described. In this case, Aranesp can only be approved
after the patient has failed Retacrit. The Plan has agreed to coverage of Retacrit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp (J0881).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left atrial appendage closure (LAAC) procedure.

You asked the Plan to pre-approve the LAAC procedure. You say that this is medically necessary and should be covered. The Plan denied your request. The Plan says that this cannot be covered because the enrollee is not in a clinical trial.

The Plan follows Medicare rules. Medicare rules say that LAAC procedures may be covered when certain criteria are met, and the outcomes will be reported to an approved national clinical registry. 

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 LAAC procedure. Our reviewer says that review of the available evidence shows that criteria are met, and that this surgery is medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has atrial fibrillation. The record indicates that the enrollee has a CHADS2-VA2Sc of 6 and a HAS-BLED score of 3. Additional information from the plan indicates that the provider and facility participate in an approved clinical registry. The elements of the coverage criteria are 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 LAAC procedure have been met. Therefore, we decided that the Plan has to pre-approve left atrial appendage closure (LAAC) procedure.

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 treatment with Prolia.
You asked the Plan to pre-approve Prolia. You say that the requested drug is a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for Medicare Part B coverage for drugs or
biologicals have not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the
medication does not represent an expense to the physician and will not be included in the physician's bill, it is
not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve treatment
with Prolia.
Benefits for Prolia 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 waive the copayment for the medical eye exam you had with an ophthalmologist on March 30, 2021.
You asked the Plan to waive the copayment for the medical eye exam. You say that you thought you were entitled to a free eye exam and you don't remember them doing any diagnosis or treatment of an eye disease. You say this was just a routine exam. The Plan denied your request. The Plan says you were charged this copayment 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 a $35 copayment for medical eye exams.
You have been asked to pay a $35 copayment for the medical eye exam. The medical records from this date of service show that you were also evaluated for cornea-dry eye syndrome and provided instruction to begin using artificial tears as well as a review of an age-related cataract of the right eye. Because you received care related to these medical conditions, the medical eye exam copayment applies. 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 the medical eye exam you had with an ophthalmologist on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve head gear (A7035) for a positive airway pressure (PAP) device at a 2 month interval.
You asked the Plan to pre-approve the head gear for a PAP. You say that you require the head gear sooner than six months apart. The Plan denied your request. The Plan says the rules say that 1 per 6 months is reasonable.
The Plan must follow Medicare rules. Medicare rules say that a maximum of 1 per 6 months would be considered reasonable and necessary. So, anything sooner is deemed not reasonable or necessary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the head gear for a PAP have not been met. Therefore, we decided that the Plan does not have to pre-approve head gear (A7035) for a positive airway pressure (PAP) device at a 2 month interval.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements 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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a history of osteoporosis-related fracture or a trial of zoledronic acid before they will approve the requested drug. The enrollee has not tried and failed zoledronic acid and has no history of an osteoporosis-related fracture. There is no documentation provided indicating that zoledronic acid would likely be less effective or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407 & 81408) provided February 11, 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 this service is not covered under Medicare rules.
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 81407 & 81408 are not supported in the medical record. Specifically, Medicare denies
coverage for all cardiovascular risk assessment testing/panels. 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 (81407 & 81408) provided February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, periapical x-rays, and recement of crown rendered on June 14, 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 enrollee exhausted the benefit maximum.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $2,000
for supplemental dental benefits per year. We looked at the file and the Plan's rules. The file shows that the enrollee had used the entire $2,000 benefit for supplemental dental services prior to having the services at issue rendered. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, periapical x-rays, and recement of crown rendered on June 14, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electroconvulsive therapy (ECT).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 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 services are not medically necessary. Our physician reviewer found the enrollee has schizophrenia spectrum disorder. He has previously received treatment with Abilify, Seroquel, Latuda Zyprexa, Risperdal and Haldol medications. He has not been treated with clozapine. The clinical guidelines for use of ECT, based on the American Psychiatric Association practice management guidelines, list the use of clozapine alone for the treatment of treatment-resistant schizophrenia spectrum disorder. The enrollee has not tried clozapine and the records do not show any contraindications to the medication. The use of ECT is therefore 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve electroconvulsive therapy (ECT).
Appeal type: Hospice
Decision: Unfavorable

We decided the Plan does not have to pay for testing services provided to the enrollee on November 3, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says based on the enrollee's hospice status at the time of service, this claim must be submitted
to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit
for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for
testing services provided to the enrollee on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81301, 81201, 81318, 81321) provided
on March 31, 2021.
You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your
request. The Plan says this was not billed correctly.
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 81301, 81201, 81318, and 81321 is not supported in the medical record. Specifically,
these codes were used to report Guardant360 testing, which should be billed with 81479.
Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been
met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81301, 81201, 81318,
81321) provided on March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided on March 13, 2021 by an out-of-network (OON) provider.

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 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 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 the home visit provided on March 13, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided November 8, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that you were told there would be no copayment. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $260 copayment for Medicare-covered ambulance transport (one-way). The enrollee has been asked to pay a $260 copayment for the ambulance services. This service falls within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided November 8, 2020.
Your complaint about potentially being provided misinformation about whether the copayment would be applied to this service is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the urology office visit and the chemotherapy drugs you received on May 18, 2021.
You asked the Plan to waive the cost sharing for the urology visit and the chemotherapy drugs. You say that these costs are ridiculous for the doctor only spending 5 minutes with you. The Plan denied your request. The Plan says you were charged this cost sharing 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 a $40 copayment for visits with a specialist and 20% coinsurance for chemotherapy drugs. You have been asked to pay a $40 copayment for the urology visit and 20% coinsurance for the chemotherapy
drugs. The allowed amount for the chemotherapy drugs you received is $1373.60, so your 20% coinsurance amount equals $274.72. This means that you have been asked to pay the correct amounts 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 sharing for the urology office visit and the chemotherapy drugs you received on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of
the spine you had on March 9, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you were told by the provider that your
copayment was only $95. You say that you called back and they advised that was only an estimate and now
you're being charged an additional $120.43. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that because the allowed amount for this service ($215.43) is less than your
copayment obligation, you are responsible for the full allowed 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 $225
copayment for diagnostic and nuclear medicine radiological services. You have been asked to pay a $225 copayment for the MRI. The MRI falls within the diagnostic and nuclear
medicine radiological 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 the
magnetic resonance imaging (MRI) of the spine you had on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit system (A9270).
You asked the Plan to pre-approve a transit system. You say that the requested item is a medical necessity for
you. The Plan denied your request. The Plan says rules for coverage have not been met because the requested
item is for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a transit system (A9270).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have copayment for outpatient hospital services provided by a participating provider on November 13, 2020.

You asked the Plan copayment for outpatient hospital services. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $150 copayment for outpatient hospital services/in-network. 

You have been asked to pay a $150 copayment for outpatient hospital services. The correct copayment has been applied to the services that were provided. Outpatient hospital services fall within the outpatient hospital services/in-network 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 copayment for outpatient hospital services provided by a participating provider on November 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 20, 2021 by an out-of-network (OON) provider.
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 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 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 the laboratory services provided on April 20, 2021 by an out-of-network (OON) provider.