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

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the plan's preferred viscosupplements are Orthovisc and Monovisc which do not require authorization.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular risk screening assessment provided to the 
enrollee on February 24, 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 cardiovascular risk screening assessment is not covered by Medicare. 
 
Medicare does not cover cardiovascular risk assessment. The Plan contract states outpatient lab services may 
require prior authorization. The Plan did not authorize this testing and the results of this testing would not 
change or determine a specific treatment plan for the enrollee. Medicare coverage criteria are not met. 
Therefore, we decided that the Plan does not have to pay for cardiovascular risk screening assessment provided 
to the enrollee on February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on August 25, 2020. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   
We looked at the file and Medicare rules. The documentation shows that the services in question were billed 
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which 
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on August 25, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve Urolift for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no documentation in the clinical notes stating a trial and failure of conventional medication therapy.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the medical records indicate that the enrollee has symptomatic benign prostatic hyperplasia that has failed medical therapy. The enrollee's age (78 years old), prostate size (39.6 cc) and maximum flow rates (13.5 cc/s) are all appropriate for Urolift coverage. 

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve Urolift for the enrollee.

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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services you received on June 
28, 2021. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you have a membership 
with a different ambulance company.  You said that when your husband called 911, he requested that the 
ambulance company with whom you have a membership come, but a different company came instead. 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 $285 
copayment for emergency ambulance services.  
 
You have been asked to pay a $285 copayment for the ambulance services. This copayment applies regardless 
of what ambulance memberships you may have. 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 services you received on June 28, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dialysis services coded as J0604, 84460, 85018, 84520, 84100, 84132, 84520, 82310, 82435, 84295, 82565, 84075, 84155, 82040, and 82374 provided January 3, 2021 to January 21, 2021.

You asked the Plan to pay for the dialysis services. You say that the medication given is supported by the attached medical records. Also, per CMS guidelines all medication is bundled. Please review and reprocess claim. The Plan denied your request. The Plan says these services are not eligible for separate payment.

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 find that CPT codes J0604, 84460, 85018, 84520, 84100, 84132, 84520, 82310, 82435, 84295, 82565, 84075, 84155, 82040, and 82374 is not supported in the medical record. Specifically, J0604 is incidental to 90937-G4-V5 which was allowed for each date of service. Separate charges for J0604 are not eligible for payment. Codes 84460 CF, 85018, 84520-CD, 84100-CD, 84132-CD, 84520-CD-91, 82310-CD, 82435-CD, 84295-CF, 82565-CD, 84075-CD, 84155-CD, 82040-CD, and 82374-CD are laboratory tests that are subject to end stage renal disease consolidated billing and are not separately billable. Based on this information, we decided that Medicare rules for coverage of the dialysis services have not been met. Therefore, we decided that the Plan does not have to pay for the dialysis services coded as J0604, 84460, 85018, 84520, 84100, 84132, 84520, 82310, 82435, 84295, 82565, 84075, 84155, 82040, and 82374 provided January 3, 2021 to January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Prolia injection you had on June 25, 
2021. 
 
You asked the Plan to waive the coinsurance for the Prolia injection. You say that you don't understand why 
you are receiving this bill.  You said this was authorized and you were not charged for the first injection. The 
Plan denied your request. The Plan says you were charged this coinsurance 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 Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Prolia injection. The Prolia injection falls within the 
Medicare Part B drugs benefit category. This cost sharing applies even if the service is authorized and 
regardless of what you may have paid for past injections. 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 the Prolia injection you had on June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need extra trips. The 
Plan denied your request. The Plan says you have exhausted your Plan's benefit for this service. 
 
  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from October 21, 2019, to October 25, 
2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until February 19, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the services provided from October 21, 2019, to October 25, 2019.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for the aspiration of the pleural space (32555) provided on April 27, 2021. 
 
You asked the Plan to pay for the aspiration of the pleural space. You say that you would like reconsideration 
because this service was billed correctly and is not subject to NCCI edits. The Plan denied your request. The 
Plan says that this service is part of the global surgery package for CPT code 36561. 
 
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 Plan denied this service as being part of the global surgery 
package for CPT code 36561. The Plan has not submitted any record indicating that CPT code 36561 has been 
rendered or billed. Without this information we are unable to determine if CPT code 32555 is included in a 
global surgery package. It is the burden of the Health Plan to substantiate their denial with evidence. This 
denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay 
for the aspiration of the pleural space (32555) provided on April 27, 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 reimburse you an additional amount for the purchased oxygen
equipment (E1390) provided on January 27, 2021.

You asked the Plan to reimburse you an additional amount for the purchased oxygen equipment. You say that
you would like additional reimbursement for the oxygen equipment that you purchased. The Plan denied your
request. The Plan says the coinsurance that has been assessed is correct.

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 rules also say that payment is not made for purchases of this type of
equipment.

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. Additionally, the record indicates that this
equipment was purchased. Payment may not be made for purchases of this type of equipment. Please note,
though this equipment is not covered, the Plan elected to make some payment. Therefore, we decided that the
Plan does not have to reimburse you an additional amount for the purchased oxygen equipment (E1390)
provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99212), administration service, and laboratory testing provided on May 18, 2021.

You asked the Plan to pay for office visit, administration service, and laboratory testing. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because code 99212 has an integrated outpatient code editor (IOCE) payment status indicator of B meaning that this procedure code is not recognized by the outpatient prospective payment system and the entire claim should be returned to the provider.

The Plan must follow Medicare rules. Medicare rules say that codes with a payment status indicator of B always return IOCE edit 62, meaning that the code is not recognized by Medicare for outpatient prospective payment system (OPPS) and another code for the same service may be available. Claims which have edit 62 result in a disposition of Return To Provider, meaning the whole claim is returned to the provider and may be resubmitted when the problems are corrected. 

We looked at the file and Medicare rules. Code 99212 has an OPPS payment status indicator of B, resulting in an IOCE edit of 62. This means that Medicare does not recognize code 99212 for OPPS payment and the whole claim is returned to you. You may resubmit the claim when the problem has been corrected. Based on this information, we decided that Medicare rules for coverage of office visit, administration service, and laboratory testing have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99212), administration service, and laboratory testing provided on May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the evaluation and management services provided on April 
25, 2021. 
 
You asked the Plan to pay for the services provided. You say that the clean claim was coded correctly. The 
Plan denied your request. The Plan says the claim was processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. We find that CPT code 99222 was billed on the same date as procedure 
36620. Code 36620 has a global surgery indicator of 000, which indicates a minor procedure. In general, 
evaluation and management services provided on the same date of service as the minor surgical procedure are 
included in the payment for the procedure. 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 evaluation and management services provided on April 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiovascular genetic risk assessment provided to the 
enrollee on November 9, 2020. 
 
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your 
request. The Plan says this testing is a screening and is not covered by Medicare. 
 
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 cardiovascular genetic risk assessment provided to the enrollee on November 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings (A6545) for the enrollee. 
 
You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied 
your request. The Plan says the criteria was not met in this case. 
 
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 the stockings. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Velcro compression stockings were requested. Velcro wraps are easier for him to use and do 
not cause trauma to legs. Regular compression stockings were tried and failed due to them causing new wounds 
related to skin tearing. As the enrollee does not have an active open leg wound and no plans to reduce scarring 
or joint contracture, the criteria has not been met. 
 
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 stockings have not been met. Therefore, we decided that the Plan does not 
have to pre-approve compression stockings (A6545) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided June 8, 2021. 
 
You asked the Plan to pay for the intraoral x-rays. You say that you had to get a new dentist because your 
previous dentist was no longer part of the Plan's network. The Plan denied your request. The Plan says the 
exam from this date of service has been reprocessed with a one-time exception for coverage, however the 
complete series of x-rays is not a covered service under your 2021 benefits. 
 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intraoral - complete series of radiographic images (D0210) provided June 8, 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. You say that the enrollee cannot be adequately cared 
for in her condition at a skilled nursing facility. You say that the enrollee has ongoing and complex medical 
needs and is stable and suitable for transfer to an LTACH. You say that the enrollee requires close medical 
monitoring, daily physician management, and intensive skilled services. The Plan denied your request. The 
Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
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 reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee 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 and able to be furnished safely and effectively only on an inpatient basis. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0483) provided June 10, 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 documentation does not support the billed services. 
 
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 G0483 is Drug Testing, 22 or more drug classes. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 
results for 22 or more drug classes. 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 
(G0483) provided June 10, 2021.