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

We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network
(OON) provider on January 8, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for the office visit (99213) rendered by
the out-of-network (OON) provider on January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor provided on February 22, 2021.
You asked the Plan to pay for the supply allowance (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says medical records from the attending physician documents the enrollee does not use insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The progress notes are a year old. There are no medical records to show if the enrollee is currently using insulin with at least three daily injections or has had a 6 month visit to assess adherence to the CGM regimen. Based on this information, we decided that Medicare rules for coverage of the supply allowance (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for a therapeutic continuous glucose monitor provided on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on December 3, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on April 28, 2020.
You asked the Plan to pay for the out-of-network medical services. You say that you would like to appeal this bill. The Plan denied your request. The Plan says these services were neither provided nor authorized by the Plan, so you were appropriately charged Original Medicare out of pocket costs for these services.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on April 28, 2020. Please note that this decision is limited to the April 28, 2020, date of service. If you wish to appeal other dates of service, please contact the Plan directly.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pelvic ultrasound you received at an outpatient hospital facility on April 6, 2021.

You asked the Plan to waive the copayment for the pelvic ultrasound. You say that this copayment should be waived because this is copay stacking. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that it has already waived one of the $100 copayments charged, so you are only responsible for one $100 diagnostic radiology copayment for this date of 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 $100 copayment for ultrasounds.

You have been asked to pay a $100 copayment for the pelvic ultrasound. 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 the pelvic ultrasound you received at an outpatient hospital facility on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the chemodenervation procedure and the Botulinum Toxin (Botox) injections you received at an outpatient hospital facility on December 10, 2020.
You asked the Plan to waive the cost sharing for the chemodenervation procedure and the Botox injections. You say that this amount is higher than usual. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the chemodenervation procedure, since the allowed amount ($104.72) is less than your copayment for this service, you are responsible for the full allowed amount. In addition, the Plan says that the allowed amount for the Botox injections you received was $1818, so 20% coinsurance of that amount is $363.60.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B drugs and a $250 copayment for outpatient procedures. You have been asked to pay a $250 copayment for the chemodenervation procedure and 20% coinsurance for the Botox injections. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the chemodenervation procedure and the Botulinum Toxin (Botox) injections you received at an outpatient hospital facility on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral surgeon services provided on March 12, 2021 and
March 15, 2021.
You asked the Plan to pay for the oral surgeon services. You say that you were told the doctor did not take
Medicare, but you should expect some reimbursement. The Plan denied your request. The Plan says the
provider is on the Medicare opt out list.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the oral
surgeon services provided on March 12, 2021 and March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on March 26, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the provider is not Medicare-certified.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. 

We looked at the file and Medicare rules. The file shows that the provider was not Medicare-certified for the date of service in question. Therefore, we decided that the Plan does not have to pay for the physician services rendered on March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested treatment is experimental/investigational.
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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Evenity (J3111).

You asked the Plan to pre-approve Evenity. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.

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 requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of Prolia or Reclast before they will approve the requested drug. In this case, the enrollee has not tried and failed a required drug. There is no documentation indicating that either one of the Plan's required drugs is likely be less effective and/or likely 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 Evenity have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Evenity (J3111).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay for the pay for the medical services provided on February 26, 2021.
You asked the Plan to pay for the medical services. You say that these services should be covered because they
were authorized. The Plan denied your request. The Plan says that these CPT codes were not supported because
you did not provide medical records from this date of service.
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, Current Procedural Terminology
(CPT) codes J2350, J2930, 96413, 96451, and 96375 were originally denied by the Plan because they were no
medical records from February 26, 2021 to support that these services had been provided. The only medical
records originally submitted to the plan were from February 9, 2021, and June 18, 2020. However, you have
sent the medical records for date of service February 26, 2021 directly to us. The following is based on a
review of these records.
We find that CPT code J2350 is supported by the medical record. The definition of this code as billed is 600
units of Ocrelizumab, also known as Ocrevus. In the medical records from this date of service, it is clearly
documented that this patient received two separate intravenous administrations of Ocrevus at 300mg each, for a
total of 600mg. That is why this code is supported.
For CPT code J2930, the medical records show an intravenous push of Solu-Medrol IV, at a dosage of 125mg,
was provided on this date of service. That is why this code is supported.
CPT codes 96413 and 96451, are supported in the medical record. The medical records from this date show
that the drug administration occurred over the course of four hours. That is why these codes are supported.
For CPT code 96375, this is simply an add-on code that is supported in the medical record. CPT code J2930
was infused for 15 minutes prior to beginning the infusion for Ocrevus. That is why this code is supported.
Based on this information, we decided that Medicare rules for coverage of the medical services have been met.
Therefore, we decided that the Plan has to pay for the pay for the medical services provided on February 26,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the parenteral nutrition rendered on January 29, 2021 to February 4, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition rendered on January 29, 2021 to February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on September 23, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 00560 is not supported.

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 00560 is anesthesia for procedures on heart, pericardial
sac, and great vessels of chest; without pump oxygenator.

We find that CPT code 00560 is not supported in the medical record. Specifically, the documentation does not
contain 220 units of anesthesia for procedures on the heart without pump oxygenator.

Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on September 23,
2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Abraxane (J9264).
You asked the Plan to pre-approve Abraxane. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for coverage of the requested drug have not been met.
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 Abraxane. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Taxol (paclitaxel) or Taxotere (docetaxel) or a contraindication to standard hypersensitivity premedications before they will approve the requested drug. The case file does not contain documentation of a trial of the Plan's required drugs or of a contraindication to standard hypersensitivity premedications. The documentation does not support that Taxol or Taxotere would likely be less effective and/or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Abraxane (J9264).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care admission and services provided from January 22, 2021, to January 23, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you were not even in this hospital for a full 24 hours before you were transferred to another facility. You do not feel there was enough care provided at this facility to warrant a copayment. The Plan denied your request. The Plan says this claim was processed correctly. You are required to pay $250 for each of the first three days of an inpatient hospital stay.

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 $250 copayment for each of the first three days of an inpatient hospital admission.

You have been asked to pay a $250 copayment for the inpatient care. You were admitted as an inpatient to this facility during the dates in question. 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 the inpatient hospital care admission and services provided from January 22, 2021, to January 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81406, 81407, 81408) provided February 16, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. We looked at the file and Medicare rules. The record shows these tests were not ordered by the treating physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81406, 81407, 81408) provided February 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit provided on
March 3, 2021.
You asked the Plan to waive the copayment for an emergency department visit. You say that you were admitted
into the hospital on March 4, 2021 from the emergency room. The Plan denied your request. The Plan says the
copayment you are being charged is 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 a $85
copayment for emergency care. Your contract with the Plan also clearly says that the copayment is waived if
you are admitted to the hospital within one day for the same condition.
You have been asked to pay a $85 copayment for an emergency department visit. The records show that you
went to the emergency room and were not admitted into the hospital but placed in observation while tests were
conducted. The EOC confirms that $85 is the required copayment for this service. 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 department visit provided on March 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive community support services (H2015) provided on May 5, 2021.

You asked the Plan to pay for community support services.. You say that you only saw the provider to fill out a form for a passport and did not have a consultation or appointment related to psychiatric services. The Plan denied your request. The Plan says rules for payment have not been met because the service at issue is not for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member are not covered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of community support services. have not been met. Specifically, the service at issue in this case is not for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Therefore, we decided that the Plan does not have to pay for comprehensive community support services (H2015) provided on May 5, 2021.