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

We decided that the Plan does not have to pay forthe x-ray services coded 71045 provided on January 7, 2020.You asked the Plan to pay forthe x-ray 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 71045 for the x-ray services has a bundled relationship with code 71100and 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 forthe x-ray services coded 71045 provided on January 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the power recliner, grab bar, and rollator, purchased from suppliers not certified by Medicare, from February 11, 2019 to June 17, 2019.You asked the Plan to reimburse you for the power recliner, grab bar, and rollator. You say that you had a doctor's prescription so the Plan should reimburse you. The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. The items at issue in this appeal were provided by providers not certified by Medicare.Therefore, we decided that the Plan does not have to reimburse you for the power recliner, grab bar, and rollator, purchased from suppliers not certified by Medicare, from February 11, 2019 to June 17, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit (99282) on February 11, 2020.
You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing 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 $110 copayment for emergency care. You have been asked to pay a $110 copayment for the Emergency Room visit. The Emergency Room visit falls within the emergency care 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 Emergency Room visit (99282) on February 11, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sodium Hyaluronate.
You asked the Plan to pre-approve Sodium Hyaluronate. You say that Orthovisc was previously denied. The Plan denied your request. The Plan says the enrollee has not met step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Sodium Hyaluronate. Our reviewer says that the criteria for coverage of Sodium Hyaluronate have not been met. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation submitted does not support that the enrollee has had prior treatment, contraindication, or intolerance to Orthovisc and Monovisc. The records do not state why the alternatives required by the Plan would not be as effective for the enrollee as the requested drug or would 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 Sodium Hyaluronate have not been met. Therefore, we decided that the Plan does not have to pre-approve Sodium Hyaluronate.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray (CPT 71045) provided on September 23, 2019.You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says this service has already been paid.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 71045 is "Radiologic examination, chest; single view".We find that CPT code 71045 is not supported in the medical record. Specifically, the records show that one chest x-ray was performed on the date of services in question. The plan has already paid for one unit of CPT 71045. The additional unit of CPT 71045 billed on September 23, 2019, is not supported. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met.Therefore, we decided that the Plan does not have to pay for the x-ray (CPT 71045) provided on September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient services provided out of network. You say that The Plan denied your request. The Plan says the non-emergent services were provided out of network 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 has network providers available who can provide 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 medical services provided on November 7, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to you by an out-of-network provider from February 5, 2020, to March 4, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says out-of-network services are not covered.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the servicesat 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 forthe services provided to you by an out-of-network provider from February 5, 2020, to March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation You asked the Plan to pre-approve hypoglossal nerve stimulation. You say that you are appealing to approve a medically necessary and FDA approved procedure for your well documented and unresolved life threatening medical condition.The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria.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 hypoglossal nerve stimulation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee does not have a BMI of less than 35 kg/m2. The enrollee has a BMI = 41.16 kg/m2. All of the coverage criteria have 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 hypoglossal nerve stimulation have not been met.Therefore, we decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 9 additional extractions (D7140) provided on January 15, 2020.You asked the Plan to pay for9 additional extraction. You say that your dental coverage was cancelled as of January 1, 2020 without any notification. You say that you were not given the opportunity to continue your coverage. You also say that your payment authorization for your dental coverage has not been cancelled.The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan also says the frequency limit has been exhausted.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 and extractions are a covered service, the frequency limit for this service has been exhausted. The record shows that the Plan paid for 2 extractions that you received on January 15, 2020.Therefore, we decided that the Plan does not have to pay for the 9 additional extractions (D7140) provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the mattress purchased on October 21, 2019.You asked the Plan to reimburse you for the mattress. You say that that the mattress was for a covered hospital bed so the Plan should reimburse you. The Plan denied your request. The Plan says you obtained durable medical equipment from a provider who does not participate with Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for itemsprovided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to reimburse you for the mattress purchased on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on February 27, 2019.
You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you had a specialist visit on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $25 copayment for each Medicare-covered specialist visit. We looked at the file, the Plan's contract and Medicare rules. The file shows you had a specialist visit on February 27, 2019. You have been asked to pay a $25 copayment for the specialist visit. The specialist visit falls within the Physician/Practitioner 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. Please note, the file shows your provider billed additional services beyond the scope of your annual exam. Therefore, we decided that the Plan does not have to waive the copayment for the specialist visit provided on February 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hyalgan/Supartz injection.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says no steroid injections have been tried at this point.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found you have not tried a corticosteroid injection in the knee joint. The documentation does not support that the requested injection is medically reasonable and necessary or safe and effective for you.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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Hyalgan/Supartz injection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on October 31, 2019.
You asked the Plan to pay for train of four testing. You say that you should not be responsible for this charge. The Plan denied your request. The Plan says payment of this service is bundled into other 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. We find that CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and destruction of lesion(s) by physical or chemical method (D7465) provided on December 30, 2019 and January 16, 2020 by an OON provider.
You asked the Plan to pay for the incisional biopsy and destruction of lesion(s). You say that you contacted the Plan and were told that this provider was in network. You also say that this provider told you they were no longer contracted with your Plan. The Plan denied your request. The Plan says no services are available for procedures performed by OON providers. The Plan also says that these services are not covered by the Plan.
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 covered when they are received OON. These services are also not listed as being covered by your plan. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7286) and destruction of lesion(s) by physical or chemical method (D7465) provided on December 30, 2019 and January 16, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on December 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe 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 provided wereneither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 has network providers available who can provide 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 forthe laboratory services provided on December 11, 2019 by an out of network (OON) provider.
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 for your safety and your
ability to recover to the fullest extent. 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 above.
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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical
status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional
multiple therapies, however your functional level does not require or indicate that this therapy must be in an
IRF with an intensive level program.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient rehabilitation services from December 9, 2019 through December 31, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient rehabilitation services. You say that the charges billed should be covered by the plan as a continuation of your post-surgical hospitalization. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient rehabilitation services from December 9, 2019 through December 31, 2019 provided by an in-network provider. Since there were two (2) separate admissions and discharges for two different types of services, two cost-shares are applicable. You are asked to pay a $295 copayment for days 1-5. Your EOC states, enrollees must pay a $295 copayment per day (per in-network Medicare-covered stay), which includes day of admission and day of discharge, for days 1-5. 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 inpatient rehabilitation services from December 9, 2019 through December 31, 2019 provided by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 28, 2019.
You asked the Plan to pay for the pump assembly and operation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per the Physician Fee Schedule, CPT code 99190 has a status code of X meaning it is a statutory exclusion.
The Plan must follow Medicare rules. Medicare rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump assembly and operation have not been met. Specifically, payment for this service is included in the DRG payment to the facility and is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump (99190) provided on August 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that you have no other way to your therapy sessions. The Plan denied your request. The Plan says your benefit only allows 30 trips 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 30 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's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the urinary intermittent catheter with insertion supplies provided on January 23, 2020.
You asked the Plan to waive the coinsurance for the catheters. The Plan denied your request. The Plan says that there is a 20% coinsurance for prosthetic devices and medical supplies.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for prosthetic devices and medical supplies. You have been asked to pay a 20% coinsurance for the catheters. The catheters fall within the prosthetic devices and medical 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 coinsurance for the urinary intermittent catheter with insertion supplies provided on January 23, 2020.