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

We decided that the Plan does not have to pay for a follow-up visit provided on July 30, 2019 by an out of network (OON) provider. You asked the Plan to pay for a follow-up visit. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 a follow-up visit provided on July 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a coccygeal nerve block. You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not medically necessary. 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 block. Our reviewer says that the requested block is considered medically reasonable and necessary in this case. Our physician reviewer found nerve block with steroid of the ganglion Impar is standard therapy coccydynia, along with manipulation of the coccyx, that has not responded to conservative therapy. The requested procedure is medically reasonable and 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 the block have been met. Therefore, we decided that the Plan has to pre-approve a coccygeal nerve block. 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 Freestyle Libre Continuous Glucose Monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. 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 CGM. Our reviewer says that rules for coverage were not met. Our physician reviewer found the enrollee is not using insulin. The record does not show why the enrollee must check her Blood Glucose more than 4 times daily. The record does not show that a standard glucometer would not meet the enrollee's needs. 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on June 18, 2019.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this service, train of four, is considered integral to the primary procedure, neurophysiology monitoring and therefore is part of a bundled 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, the CPT Code Manual definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure." We find that CPT code 95999 is not supported in the medical record. Specifically, payment for this code is included in the payment for the neurophysiology monitoring. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (CPT 95999) provided to the enrollee on June 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1820) provided to the enrollee on July 8,
2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. When conducting a review of a
covered DME item, ordered by a physician, the contractor shall ensure that the physician saw the beneficiary
and conducted a face-to-face assessment. There is nothing in the documentation that supports the billed code.
Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1820) provided to the enrollee
on July 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management service, 30 minutes or less (99238) provided November 6, 2019. You asked the Plan to pay for hospital discharge day management service. You say that according to the Medicare file, the enrollee is not enrolled in Medicare, please verify and update file so our claim can be processed accordingly. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. 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 hospital discharge day management service, 30 minutes or less (99238) provided November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final restoration) on tooth #29 (D3320).
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under the member's contractual dental policy.
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 services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, premolar tooth (excluding final restoration) on tooth #29 (D3320).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 31, 2019 to August
30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you were told that this provider was innetwork.
The Plan denied your request. The Plan says the denial of payment for these services is correct
because this provider is out-of-network with the Plan.
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 May 31, 2019 to
August 30, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 15, 2019 to June 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you request reconsideration of the denial of this admission. The Plan denied your request. The Plan says the inpatient stay was not medically necessary.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records provided indicate that the admitting physician expected the enrollee's admission to span two midnights. He had stable vital signs, noted improved mentation, and no complaints at the time of admission. Care provided to the enrollee was observation level. There were no advance interventions or complex medical conditions. Inpatient services were not supported by the documentation.
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 not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 15, 2019 to June 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 5, 2019 by an out of network (OON) provider. You asked the Plan to pay for lab tests. You say that these tests were ordered by a doctor. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was obtained. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 lab tests provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the bevacizumab administered via intravitreal eye injection on September 11, 2019 billed with one unit of CPT code J9035.
You asked the Plan to pay for the drug as billed. You say that this was correctly billed and should be approved for payment. The Plan denied your request. The Plan says the incorrect code was used for billing intravitreal bevacizumab.
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 J9035 is Injection, bevacizumab, 10 mg. We find that CPT code J9035 is not supported in the medical record. Specifically, the operative note clearly indicates that 0.05mL with 1.25mg of bevacizumab were injected. This does not support the billing of a unit of J9035 which corresponds to 10mg, which is much more than was provided. There is a more appropriate code which can be used for dosages under 10mg. Based on this information, we decided that Medicare rules for coverage of the drug as billed have not been met. Therefore, we decided that the Plan does not have to pay for the bevacizumab administered via intravitreal eye injection on September 11, 2019 billed with one unit of CPT code J9035.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post-stabilization care provided from May 25, 2019 to May 27, 2019. You asked the Plan to pay for post-stabilization care. You say that the services were necessary. The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 post stabilization care. Our reviewer says that the services were not medically necessary. Our physician reviewer found the review indicates that the enrollee was hemodynamically stable for ambulance transport with monitoring to a Plan facility for observation/admission level of care services after the emergency room evaluation on May 25, 2019. There was no documentation provided necessitating post-stabilization care May 25, 2019 to May 27, 2019 at the non-Plan facility. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of post stabilization care have not been met. Therefore, we decided that the Plan does not have to pay for post stabilization care provided from May 25, 2019 to May 27, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast reconstruction surgery provided from February 19, 2019 to February 20, 2019. You asked the Plan to waive the copayment for the breast reconstruction surgery. You say that the coinsurance was calculated on an out-of-network basis. You say this is incorrect because you are enrolled in a plan with out-of-network coverage. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay 40% coinsurance for Medicare-covered surgery or other services provided to you at an out-of-network outpatient hospital or other facility charges and physician or surgical charges. The enrollee has been asked to pay $4,017.40 which is 40% of the allowed amount for the breast reconstruction surgery. The allowed amount is $14,563.24. You have been asked to pay less than the standard amount for the breast reconstruction surgery. The record shows the hospital is an out-of-network provider. The breast reconstruction surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 breast reconstruction surgery provided from February 19, 2019 to February 20, 2019. Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 18, 2019.
You asked the Plan to pay for this testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed above, are not covered. The test at issue in this appeal, this testing, 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 genetic testing provided to the enrollee on June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for antibody evaluation tests provided out of network. You asked the Plan to pay for this service. You say that this testing was medically necessary. The Plan denied your request. The Plan says it has not been established that this service was medically necessary as opposed to having been a screening. The Plan states medical records were requested from your physician to confirm this testing was necessary. Those records were not provided. This testing was done out of network without prior authorization. Medicare coverage criteria for this testing are not met. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. You did not have prior authorization for this testing. Your physician has not confirmed this testing was medically necessary. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for antibody evaluation tests provided out of network on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visit, the Part B injections, the laboratory work, or the inpatient hospital stay provided from June 5, 2019 to October 17, 2019. You asked the Plan to waive the cost share for the specialist office visit, the Part B injections, the laboratory work, and the inpatient hospital stay. You say that the coverage for most in-and out-of-network benefits are the same. You say you were approved for out-of-network services The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 out-of-network deductible that applies towards Part B injections, a $40 copayment for each Medicare-covered visit with an out-of-network specialist, 20% coinsurance per day, per provider, for each out-of-network Medicare-covered Part B drug obtained in a provider's office or outpatient setting after your yearly deductible is met, a $35 copayment for out-of-network Medicare-covered lab services, and a $150 copayment per day, days 1-6 for each out-of-network Medicare-covered hospital admission/stay. The Part B injections you asked the Plan to waive the deductible for falls within the "Medicare Part B prescription drugs" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 out-of-network deductible that applies towards Part B injection. The plan contract also says you owe a total of $457.42 for the specialist office visit, the Part B injections, the laboratory work, and the inpatient stay. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. a $40 copayment; 20% coinsurance; a $35 copayment; a $150 copayment. The record shows you received services with out-of-network providers. This cost sharing is a contractual obligation that had not been met at the time the specialist office visit, the Part B injections, the laboratory work, and the inpatient hospital stay was received on June 5, 2019 to October 17, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visit, the Part B injections, the laboratory work, or the inpatient hospital stay provided from June 5, 2019 to October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthoses provided on August 12, 2019. You asked the Plan to pay for the shoulder-elbow-wrist-hand orthoses (L3960). You say that the orthoses are medically necessary. The Plan denied your request. The Plan says criteria for the orthoses were not met. 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 shoulder-elbow-wrist-hand orthoses (L3960). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer found the enrollee's chief complaint was chronic pain located in the left shoulder and right shoulder. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the shoulder. 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 shoulder-elbow-wrist-hand orthoses (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthoses provided on August 12, 2019.