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

We decided that the Plan does not have to pay for the office visit and testing provided on January 4, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit and testing. You say that the provider became in-network in February 2021 and would like consideration at the contracted rate. The Plan denied your request. The Plan says you did not request prior authorization as required.
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 services at issue. We found no exception that would require the Plan to pay for the services. Therefore, we decided that the Plan does not have to pay for the office visit and testing provided on January 4, 2021 by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that orthotics are needed to support your balance and
your pain from walking. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on April 3, 2021.
You asked the Plan to pay for the paramedic intercept services. The Plan denied your request. The Plan says
this item is not a covered benefit. The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by
an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances.
Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as
defined above. It is noted that the only State in which these criteria are met is New York.
The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural
according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the
paramedic intercept services provided on April 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax
(71260) and pelvis (74177).
You asked the Plan to pre-approve CT scans. You say that this is a necessary follow-up. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CT scans. Our reviewer says that the
requested CT scans are not medically necessary. Our physician reviewer found previous CT scans show
stability and the lesions are most likely benign. The enrollee's prostate-specific antigen (PSA) is not rising.
Further imaging is not necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have
to pre-approve a computed tomography (CT) scan of the thorax (71260) and pelvis (74177).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that you remain very depressed and
are not able to contract for safety outside a hospital setting. You state you are at high risk for suicide. The Plan
denied your request. The Plan says that the stay is not medically necessary.
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. It appears that the plan's contracted delegate was provided the records for this
admission and has failed to forward them to support the decision to deny based on no medical necessity.
Therefore, we decided that the Plan has to pre-approve inpatient mental health care.
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 pre-approve a cup holder (K0108).
You asked the Plan to pre-approve a cup holder. You say that this item is necessary. The Plan denied your request. The Plan says an item that allows you to perform leisure or recreational activities is non-covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a cup holder (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for drug administration visits provided from
October 21, 2019, to January 11, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you are appealing these charges.
The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $35
copayment in 2019 and $25 copayment in 2020 and 2021 for each specialist visit. There were 4 visits in 2019,
resulting in a copayment amount of $140. There were 14 visits in 2020, resulting in a copayment amount of
$350. There was 1 visit in 2021, resulting in a copayment amount of $25. Therefore, your total copayment
obligation is $515.
You have been asked to pay $35 copayment in 2019 and $25 copayment in 2020 and 2021 for each specialist
visit. Specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for drug administration visits provided from
October 21, 2019, to January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 1, 2021 to February 3, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that at the time of service, the enrollee presented the wrong insurance card. When the correct one was presented, you were unable to notify the Plan within the specified timeframe. In addition, this admission was medically necessary and met Medicare guidelines. The Plan denied your request. The Plan says that the enrollee could have been treated at an outpatient observation level rather than inpatient.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 1, 2021 to February 3, 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive hearing test (92557) and the evoked
auditory test, limited (92587) provided on February 4, 2021.
You asked the Plan to pay for the hearing services. You say that the services are not related to the enrollee's
hospice diagnosis. The Plan denied your request. The Plan says the enrollee's claim would be covered under
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the
last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify
the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the comprehensive hearing test (92557) and the evoked auditory test, limited (92587) provided on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit and laboratory services rendered on March 11, 2021 to May 12, 2021.
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments were 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 a $5 copayment for each primary care visit and a $20 copayment per visit for laboratory test.
Review of the file shows that you received primary care services on March 11, 2021. You have been asked to pay a $5 copayment for these services. these services fall within the primary care visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received laboratory services on March 11, 2021. Per the contract with the Plan, there is a $20 copayment per visit for laboratory test. However, the Medicare allowed amount for these services was $13.86. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $13.86 for these services.
The file shows that you received primary care services on April 8, 2021. You have been asked to pay a $5 copayment for these services. these services fall within the primary care visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received laboratory services on April 8, 2021. Per the contract with the Plan, there is a $20 copayment per visit for laboratory test. However, the Medicare allowed amount for these services was $13.86. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $13.86 for these services.
The file shows that you received primary care services on May 12, 2021. You have been asked to pay a $5 copayment for these services. these services fall within the primary care visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
The file shows that you received laboratory services on May 12, 2021. Per the contract with the Plan, there is a $20 copayment per visit for laboratory test. However, the Medicare allowed amount for these services was $13.86. Given that the allowed amount was less than the $20 copayment, you have been asked to pay $13.86 for these services.
The total amount you have been asked to pay for these services is $56.58. 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 copayments for the office visit and laboratory services rendered on March 11, 2021 to May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on February 19, 2021.
You asked the Plan to pay for a pneumatic compression device (E0675) and appliances (E0673). You say that the place of service is correct. The Plan denied your request. The Plan says the device is not covered by Medicare to prevent deep vein thrombosis and payment would have been included in the facility prospective payment.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on February 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says the requested drug does not meet 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 Evenity. Our reviewer says that the
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer
found the enrollee has postmenopausal osteoporosis. The documentation does not support that the enrollee has
tried and failed Forteo or Tymlos. The documentation does not support that Forteo or Tymlos would likely be
less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet criteria
for the requested drug.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Evenity have not been met. Therefore, we decided that the Plan does not have to
pre-approve Evenity
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you feel these services should be covered. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 13, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision of a nursing facility patient services coded 99379 provided on March 25, 2021.
You asked the Plan to pay for the supervision of a nursing facility patient 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 99379 is supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes. We find that CPT code 99379 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that these services are bundled into another service billed on the same date of service. No separate payment can be made for these services. Based on this information, we decided that Medicare rules for coverage of the supervision of a nursing facility patient services have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility patient services coded 99379 provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675) and related
accessories (E0673) provided November 6, 2020.
You asked the Plan to pay for a pneumatic compression device and related accessory. You say that you would
like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says these items are
not eligible for coverage.
The Plan follows Medicare rules. The rules state that a PCD that is used in the treatment of peripheral arterial
disease is coded as E0675 and will not be covered.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage. In addition, because the
base PCD is not covered the related accessories are also not covered. Therefore, we decided that the Plan does
not have to pay for a pneumatic compression device (E0675) and related accessories (E0673) provided
November 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on December 22, 2020.
You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request. The Plan says the documentation did not indicate that the provider discussed the need for the monitor.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the monitor. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the criteria requires that the enrollee takes three shots per day of insulin, and that the doses are adjusted based on the blood glucose levels. Given the data provided, this is not the case here. 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 monitor have not been met. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on December 22, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on February 8, 2021.
You asked the Plan to pay for an x-ray. You say that this was appropriate for the enrollee's condition. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that a physician, practitioner, or supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service (POS) code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient at the time this service was provided, but this was not reported with the inpatient POS. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on February 8, 2021.