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

We decided that the Plan does not have to pay for the rest home visit provided on January 20, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that the hospital staff failed to obtain authorization and the doctor should not be penalized. You say the 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 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 rest home visit provided on January 20, 2021
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the records indicates that the enrollee has low back pain with radiculopathy. The record indicates the
enrollee has severe spinal stenosis at L4-L5, the planned procedure level. The elements of the coverage criteria
are not satisfied. The requested service cannot be recommended.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that the use of portable IPC device home was medically necessary to prevent the onset of venous thromboembolic events. The Plan denied your request. The Plan says a PCD coded as E0676 is used only for prevention of venous thrombosis. Items that are used for a preventive service or function are excluded from coverage.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) 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 (E0676).
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve treatment with Lucentis (J2778).
You asked the Plan to pre-approve Lucentis. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says that step therapy rules have not been met because Avastin and its biosimilar drugs Mvasi and Zirabev have not been trialed.
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 Lucentis. Our reviewer says that the requested treatment is medically necessary. Our physician reviewer found that the major compounder of Avastin (Bevacizumab) in the United States has recently shut down distribution of the required step therapy drug. Consequently, there is a shortage of Avastin. The enrollee's retinal specialist documents they are currently unable to receive Avastin due to this issue and that the process of getting credentialed with another supplier can take a few weeks. Consequently, the step therapy criteria for Lucentis should be waived in order to prevent vision loss until an alternative source of Avastin is readily available. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have been met. Therefore, we decided that the Plan has to pre-approve treatment with Lucentis (J2778).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an annual eye exam (92014) provided on
November 18, 2020.

You asked the Plan to waive the copayment for an annual eye exam. You say that you were under the
impression that your annual eye exam had a $0 copayment due to an advertisement you received. 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 $15
copayment for vision care.

You have been asked to pay a $15 copayment for an annual eye exam. The EOC confirms that you pay $15 for
one annual routine eye exam. There is no evidence within the record that the services at issue are subject to
waiver of a copayment. An annual eye exam falls within the vision care benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for an annual eye exam (92014) provided on November 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on November 17, 2020, by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you called the provider's office to schedule a yearly physical and was told the provider was in-network. The Plan denied your request. The Plan says you must use network providers to get your medical care and services. The Plan also says that services were provided 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit (99204) provided on November 17, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Purewick system.
You asked the Plan to pre-approve the Purewick system. You say that this is medically necessary. The Plan denied your request. The Plan says that this is an upgraded item and exceeds medical needs.
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 the Purewick system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on March 30, 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. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that the services were billed with diagnosis code E28.2 (polycystic ovarian syndrome), which is not an appropriate diagnosis, as the enrollee is male. 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 subsequent hospital care rendered on March 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received February 26, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the copay is not fair to seniors. The Plan denied your request. The Plan says the correct cost share applied to the claim.

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 $325 copayment for Ambulance Services. 

You have been asked to pay a $325 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427) received February 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for scaling and root planning (D4341) provided December 21, 2020.

You asked the Plan to pay for the scaling and root planning. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services were not medically necessary and do not meet coverage criteria based on the Office Reference Manual.

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 scaling and root planning when the services are medically necessary and reasonable.

We looked at the Evidence of Coverage, the file, and Medicare rules. The plan did not provide sufficient medical records or a copy of the Office Reference Manual to support the denial of the service at issue. The service is listed as covered benefit. Based on this information, we decided that the Plan's rules for coverage of the scaling and root planning have been met. Therefore, we decided that the Plan has to pay for scaling and root planning (D4341) provided December 21, 2020. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits (99212, 99213) provided on February 4, 2021 and February 5, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.

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 $45 copayment for physician services rendered at an in-network specialist's office.

You have been asked to pay a $79.34 copayment ($45+$34.34) for the physician services rendered at the
in-network's specialist office. This amount is less than the applicable copayments for these services. 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 the office visits (99212, 99213) provided on February 4, 2021 and February 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided January 18, 2021
You asked the Plan to pay for the diagnostic services. You say that your company is not allowed access to patient demographic until the technologist is at the facility. These issues make getting prior authorization next to impossible. The Plan denied your request. The Plan says the technical component is subject to skilled nursing facility consolidated billing and must be billed and reimbursed by the skilled nursing facility.
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 enrollee used the equipment while inpatient in a skilled nursing facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the diagnostic services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided January 18, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on August 7, 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 99152 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 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status. 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 moderate sedation services rendered on August 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 9, 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 30117 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 30117 is excision or destruction (eg, laser), intranasal lesion; internal approach. 

We find that CPT code 30117 is not supported in the medical record. Specifically, there is no documentation of an excision or destruction of intranasal lesion. 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 surgical services rendered on December 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings (A6531) for the
enrollee.
You asked the Plan to pre-approve the stockings. You say that this is medically necessary. The Plan denied
your request. The Plan says this is only covered in the treatment of an open venous stasis ulcer.
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 stockings. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the record indicates that the enrollee has a history of lower extremity edema and
hyperpigmentation following deep venous thrombosis. The record does not indicate the presence of an open venous stasis ulcer. The elements of the coverage rule are not satisfied. 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 stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings (A6531) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided on October 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the eye exam. You say that the enrollee was in an assisted living facility and could not choose an in-network optometrist during the pandemic. 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 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 eye exam provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the automatic external defibrillator (K0606) provided on October 18, 2020, by an out of network (OON) provider.

You asked the Plan to pay for the automatic external defibrillator. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 automatic external defibrillator (K0606) provided on October 18, 2020, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bone marrow harvesting (38232) provided on March 9, 2021.
You asked the Plan to pay for bone marrow harvesting. You say that this service is payable. The Plan denied your request. The Plan says this cannot be paid without a modifier.
The Plan must follow Medicare rules. Medicare rules say that modifier "-79" and modifier "-24" modifiers were established to simplify billing for visits and other procedures which are furnished during the postoperative period of a surgical procedure, but which are not included in the payment for the surgical procedure. We looked at the file and Medicare rules. The service at issue was performed within the 90-day global period of a knee arthroscopy (29880) performed by the same physician on January 8, 2021. This service was not billed with either of the modifiers to show that it is unrelated and separately payable. Based on this information, we decided that Medicare rules for coverage of bone marrow harvesting have not been met. Therefore, we decided that the Plan does not have to pay for bone marrow harvesting (38232) provided on March 9, 2021.