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

We decided that the Plan does not have to pay forimaging services provided to the enrollee on August 16, 2020.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says code 76377 was denied because the related or qualifying servicewas not identified or allowed on the claim which is based on the AMA CPT Manual. The Plan states that 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision requires that a recognized accompanying CT, MRI, US or other tomographic procedure also be reported. The claim is incomplete and therefore upheld. ThePlan 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, this claim cannot be paid as billed due to the omission of the code required forthe accompanying service. Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pay forimaging services provided to the enrollee on August 16, 2020
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe endoscopy you had at an ambulatory surgical center on September 8, 2020.You asked the Plan to waive the copayment forthe endoscopy. You say that this procedure was recommended by your doctor and the biopsy was medically necessary.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 $350 copayment for services in an ambulatory surgery center. You have been asked to pay a $350 copayment for the endoscopy. The endoscopy falls within the services in an ambulatory surgery center 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 forthe endoscopy you had at an ambulatory surgical center on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hearing aid services from a provider not contracted
with the Plan.
You asked the Plan to pre-approve the hearing aid services. You say that you have had issues with the Plan's
contracted hearing aid vendor and would like to use another provider. The Plan denied your request. The Plan
says they only cover routine hearing services when provided through the Plan's contracted hearing aid vendor.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when received from the Plan's contracted hearing aid vendor.
We looked at the file and the Plan's rules. The file indicates that you are requesting to receive these services
from a provider other than then Plan's contracted hearing aid vendor. Based on this information, we decided
that the Plan's rules for coverage of the hearing aid services have not been met. Therefore, we decided that the
Plan does not have to pre-approve the hearing aid services from a provider not contracted with the Plan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist service provided on August 7, 2020.You asked the Plan to waive the copayment forthe specialist service. You say that you do not recall receiving the service.The Plan denied your request. The Plan says the physician is entitled to be paid for time spent on the remote diagnostic service.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Physician services. You have been asked to pay a $39.13copayment for the specialist service. The specialist service falls within the Physician services benefit category. The allowed amount for this service is $39.13 which is why your copayment is less than$40. 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 copaymentforthe specialist service provided on August 7, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 26, 2020, by an out-of-network (OON) provider.You asked the Plan to pay foroffice visit. You say that you were told that this provider was in-network.The Plan denied your request. The Plan says the denial of payment for this service 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 forthe medical services provided on August 26, 2020, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea therapeutic continuous glucose monitor.You asked the Plan to pre-approvetherapeutic continuous glucose monitor. You say that you are appealing this denial.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the documentation does not show that you test 4 times per day or use insulin 3 times per day.ThePlan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 therapeutic continuous glucose monitor. Our reviewer says that you do not meet the Medicare criteria for the requested continuous glucose monitor Our physician reviewer found you are not taking or checking insulin on a daily basis at a high enough frequency and not having frequent dosage adjustments of insulin documented.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea therapeutic continuous glucose monitor
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from March
16, 2020, to May 26, 2020, and billed under code S9328.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the status code indicator of "I" prevents payment of this code on Medicare claims.
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, code S9328 cannot be paid as billed due to the status code indicator. Medicare uses another type of
code for this service. Medicare rules for coverage of this service have not been met. Therefore, we decided that
the Plan does not have to pay for home health services provided to the enrollee from March 16, 2020, to May
26, 2020, and billed under code S9328.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug.
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or
intolerance to zoledronic acid.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia (J0897). Our reviewer says that
the drug is not reasonable or medically necessary. Our physician reviewer found there is no evidence that the
enrollee is allergic to or intolerant of zoledronic acid. There is no evidence that the enrollee has tried and not
responded to zoledronic acid. There is no documentation as to why zoledronic acid would not be expected to
be safe and effective for the enrollee. Therefore, the requested Prolia is not shown to be currently medically
necessary and reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not
have to pre-approve Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ostomy supplies provided on July 17, 2020.You asked the Plan to waive the coinsurance forthe ostomy supplies. The Plan denied your request. The Plan says that the claim paid appropriately.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 Medicare-covered prosthetic devices and medical supplies related to prosthetics, splints, and other devices. You have been asked to pay a 20% coinsurance for the ostomy supplies. The ostomy supplies fall within the Medicare-covered prosthetic devices and medical supplies related to prosthetics, splints, and other devices 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 forthe ostomy supplies provided on July 17, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance Service on July 20, 2020.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 20, 2020. The ambulance benefit is a transportation benefit.When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by THE Ambulance Service on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe MyoPro Motion G Orthotic device (CPT Code L8702).You asked the Plan to pre-approvethe device. You say that other medical devices have been tried and failed. Youstate the member should be made whole and independent again.The Plan denied your request. The Plan says your request is not medically necessary because this device has deluxe features that exceed the member's need and replaces, rather than improves thefunction of the member's arm.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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro Motion is contraindicated for use for people with rigid spasticity or significant pain such as with this member. Robotic rehab is generally supported in the literature for permanent dysfunction such with this member, however, considering the noted contraindications without a clear explanation from the treating physician as to why this member would be an exception this request for the MyoPro Motion G Orthotic device will be considered not reasonable or medically necessary for the member's condition.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe MyoPro MotionG Orthotic device (CPT Code L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvegradient compression stocking/sleeve, not otherwise specified (CPT Code A6549) and non-elastic binder for extremity (A4465).You asked the Plan to pre-approvethe items. You say that the items are necessary.The Plan denied your request. The Plan says the requested items are not a Medicare covered benefit.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the items have not been met. The Medicare rules say the following are examples of wound care items which are non-covered under the surgical dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive): Gradient compression stockings (A6549) and non-elastic binder for an extremity (A4465).Therefore, we decided that the Plan does not have to pre-approvegradient compression stocking/sleeve, not otherwise specified (CPT Code A6549) and non-elastic binder for extremity (A4465).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of prosthodontic services.
You asked the Plan to pre-approve the replacement of prosthodontic services. You say that this service is medically necessary for your condition and you would like the Plan to pre-approve the service. The Plan denied your request. The Plan says five years have not passed since the initial prosthesis was inserted.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the replacement of prosthodontic services after five years have passed since their original insertion. We looked at the file and Medicare rules. The file indicates that you first obtained the prosthodontic service in November 2016. Therefore, the Plan will not cover the replacement until five years have passed (November 2021). Based on this information, we decided that the Plan's rules for coverage of the replacement of prosthodontic services have not been met. Therefore, we decided that the Plan does not have to pre-approve the replacement of prosthodontic services.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for polysomnography (95810) provided on August 17, 2020.

You asked the Plan to pay for the polysomnography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that a review of the member's claims history does not show that a face-to-face code was billed in the previous 365 days.

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 documentation submitted does not indicate that the Plan requested an evaluation and management record. Of note, the member was not covered by the Plan prior to August 1, 2020 and the medical record includes a note of the referring physician. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for polysomnography (95810) provided on August 17, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges forinjections. We decided that the Plan does not have to reduce the cost-sharing charges forinjectionsto the amount you requested. You asked the Plan to reduce the cost-sharing charges forinjections. You say that you have never paid for injections in the past and disagree with the charges.The Plan says that the claims were processed correctly and you are being charged the correct amount.We decided that the Planhas to reduce the cost-sharing charges forinjectionsfrom the total amount of $94.66 to $18.93. The Plan contract says that there is no deductible for Medicare Part B drugs. The Plan contract also says that you must pay 20% coinsurance for Medicare Part B drugs.The plan says thatyoumust pay the total amount of $94.66 for injections. However, you cannot be asked to pay more than 20% coinsurance for MedicarePart B drugs.Therefore, we decided that the Plan has to reduce the cost-sharing charges forinjectionsfrom $94.66 to $18.93. 
We also decided that the Plandoes not have to reduce the cost-sharing charges forinjectionsto the amount you requested. 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% for injections.The allowed amount per each injection is $47.33 and 20% of that is $9.47. The total amount you owe is: $18.93. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges forinjectionsto the amount you requested. If the Plan does notagree 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the consultation (D9310) provided on July 31, 2020.
You asked the Plan to reimburse you for the dental service. You say that you had to pay for the services up front. You say that you were given this provider's name as onboard. You also say that you expect a full refund as you still need work to be completed. The Plan denied your request. The Plan says the consultation is not listed as a covered service.
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 reimburse you for the consultation (D9310) provided on July 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says CPT code 64634 was billed with a correct appropriate primary code but CPT code 64633 was not billed in accordance with Medicare National Correct Coding Initiative Policy - Medically Unlikely Edits (MUE). This is not a medical necessity denial as CPT code 64633 has an MUE value of 1, and the provider billed 2 units. Medicare billing criteria are not met.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the claim cannot be paid as billed due to an error with the number of units billed. The Plan states a corrected claim would be reviewed. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on August 19, 2020.