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

We decided that the Plan does not have to pay for the intravitreal injection of Avastin provided on May 3, 2019 billed with codes 67028 and J9035.
You asked the Plan to pay for the billed eye injection. You say that the records support the billed service. The Plan denied your request. The Plan says there is no documentation to support that an intravitreal injection was performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 67028 and J9035 not supported in the medical record. Specifically, there is no operative note provided showing that the procedure was performed. Although there is a consent form for this procedure, there is no indication that it was done or the amount of drug that was injected. Based on this information, we decided that Medicare rules for coverage of the billed eye injection have not been met. Therefore, we decided that the Plan does not have to pay for the intravitreal injection of Avastin provided on May 3, 2019 billed with codes 67028 and J9035.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveEvenity.You asked the Plan to pre-approveEvenity. The Plandenied your request. The Plan says that that there are other drugs that are preferred by your plan used to treat your osteoporosis with ankle fracture.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. Medicare now allows plans to implement step therapy in which they may require a trial of a preferred drug before allowing coverage of a requested drug. However, Medicare rules have clearly indicated that this can only be implemented if the contract clearly discloses this information in the Medicare Part B drug section of the contract. The contract provided has no such disclosure. As such, we are not able to validate the step therapy argument made by the Plan.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 that Evenity is medically reasonable and necessary in this case. The enrollee is noted to have osteoporosis. The enrollee's osteoporosis has not responded to prior treatment with Fosamax and Prolia. Evenity is indicated for the treatment of osteoporosis in patients who have failed or been intolerant to other medications. Our physician reviewer found that your condition meets criteria for Evenity.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 been met.Therefore, we decided that the Plan has to pre-approveEvenity.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance services provided on April 18, 2018.You asked the Plan to pay forthe ambulance services. You say that the claim was filed timely.The Plan denied your request. The Plan says the claim was not received within 1 calendar year from the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance services was not filed until October 14, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forambulance services provided on April 18, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on June 5, 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 Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora chiropractic office visit (99203), x-rays (72040 and 72100), and electrical stimulation (G0283) provided on November 11, 2019.You asked the Plan to pay fora chiropractic office visit, x-rays, and electrical stimulation. You say that you were not aware these services would not be covered.The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay fora chiropractic office visit (99203), x-rays (72040 and 72100), and electrical stimulation (G0283) provided on November 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 3, 2019.You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says there is evidence of misrepresented services.The Plan must follow Medicare rules. Medicare rules say that 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. We looked at the file and Medicare rules. In this case, there is insufficient evidence that the services were provided at the address reported. The records show that the Plan has made several attempts to obtain evidence to corroborate the information provided. However, none was provided. 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 the lab services provided to on June 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 18, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the physician's services.We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (96374) provided on September 20, 2019 through September 21, 2019.You asked the Plan to pay for the injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Per Medicare Medically Unlikely Edits for Outpatient Hospital Services MUE Value, CPT code 96374 has a maximums frequency per day of one.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 MUE for CPT code 96374 is 1. You billed 2 units of this code, exceeding the MUE. In addition, the MAI for this CPT code is 3, or a per day edit. These per day edits are based on criteria combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services. The record does not include any medical records or clinical information to determine if the additional unit of CPT code 96374 is medically necessary. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (96374) provided on September 20, 2019 through September 21, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveSynvisc-One for the enrollee.You asked the Plan to pre-approveSynvisc-One. You say that this is being used in treatment of the member's osteoarthritis.The Plan denied your request. The Plan says that Medicare's drug reference books (compendia) do not support using this drug to treat osteoarthritis of the ankle or foot.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that Synvisc-One is medically reasonable and necessary for the enrollee in this case. This patient has left ankle arthritis affecting his quality of life and refractory to multiple prior lines of therapy including NSAIDS and steroid injections. The goal of hyaluronic acid injections is to provide lubrication for the ankle joint, as hyaluronic acid, such as Synvisc-One mimicsthe viscous synovial fluid that naturally lubricates the ankle joint. Research suggests hyaluronic acid injections may provide longer-lasting symptom relief than steroid injections. Our physician reviewer found that the enrollee's condition meets criteriafor coverage of Synvisc-One.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have been met.Therefore, we decided that the Plan has to pre-approveSynvisc-One for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the out-of-network services. The Plan denied your request. The Plan says the utilization of in-network providers is required.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 out-of-network services.Therefore, we decided that the Plan does not have to pay for the medical services provided on July 9, 2019 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 positioning cushion/pillow/wedge (E0190) provided August 27, 2019.
You asked the Plan to pay for Positioning cushion/pillow/wedge. You say that you were told by the doctor's office post-surgical care would include positioning your head and the referral was authorized. You had to pay for the equipment and should be reimbursed. The Plan denied your request. The Plan says this item is not a covered benefit.
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 is considered a precautionary device and 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 pay for the positioning cushion/pillow/wedge (E0190) provided August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid batteries provided on November 9, 2017.
You asked the Plan to pay for the hearing aid batteries. The Plan denied your request. The Plan says there is no coverage for hearing aids or exams to fit hearing aids, therefore hearing aid batteries are not covered.
Medicare does not pay for hearing aids or related services. The Plan contract does not coverage hearing aids or exams to fit hearing aids.
We looked at the file Medicare rules and the Plan's rules. Medicare does not pay for hearing aids or related services. The Plan does not pay for hearing aids or exams to fit hearing aids. Therefore, we decided that the Plan does not have to pay for hearing aid batteries provided on November 9, 2017.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance supplies provided on August 31, 2019.You asked the Plan to pay forthe supplies (A0382). You say that the ambulance serviceand supplies were medically necessary because you neededoxygen during the transport.The Plan denied your request. The Plan says the supplies are included in the approved transport fee.Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. We looked at the file and Medicare rules. Ambulance supplies are not separately payable by Medicare. Based on this information, we decided that Medicare rules for coverage of the supplies (A0382) have not been met.Therefore, we decided that the Plan does not have to pay separately forthe ambulance supplies provided on August 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a hip x-ray (73502) provided on October 12, 2019.
You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is inappropriate to report a procedure both as a global service and as the technical or professional components. Only the global service will be allowed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 73502 26 is not supported in the record. Specifically, the record indicates that the service was paid globally. The PC billed with modifier 26 is not separately payable. Based on this information, we decided that Medicare rules for coverage of the hip x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a hip x-ray (73502) provided on October 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-contracted 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 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 October 3, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 11, 2019 by an out of network (OON) provider.You asked the Plan to pay for the laboratory testing. You say that the enrollee went to an in network physician.The Plan denied your request. The Plan says the enrollee was not referred by a network 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 provider in this case is not a network provider with the Plan. The referring provider is not a network provider either. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on September 11, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 30, 2019 by an out of network (OON) provider.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 services were rendered by a non-contracted 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 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 July 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto waive the coinsurance forEvenity injection received on November 27, 2019.You asked the Planto waive the coinsurance forthe injection. You say that you cannot afford these injections at this copay amount.The Plandenied your request. The Plansaysthe coinsurance was applied correctly according to your benefits and the services rendered.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 clearlysays that you must pay 20% coinsurance for Medicare Part B coverage drugs. You have been asked to pay 20% coinsurance for the injection. the injection falls within the Medicare Part B coverage drugs 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 Plandoes not haveto waive the coinsurance forEvenity injection received on November 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe dental services that you received from November 29, 2018 to October 2, 2019.You asked the Plan to reimburse you forthe dental services. You say that you have information that you can go back 365 days to file a claim under your dental service allowance benefit. You say that you filed a claim for services that you received in 2018 and 2019. You also say that your 2018 claim was denied for exceeding the allowed amount.The Plan denied your request. The Plan says you did not have routine dental coverage in 2018. The Plan also says that the maximum amount of $200 peryearfor 2019has been reimbursed.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 annual maximum of $200 has been reimbursed for the services you received on October 2, 2019. Additionally, you didnot have routine dental coverage in 2018.Therefore, we decided that the Plan does not have to reimburseany additional amountsforthe dental services that you received from November 29, 2018 to October 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued SNF services.You asked the Plan to pre-approvethe continued SNF services. You say that you need an authorization for this enrollee from December 31, 2019 to January 31, 2020.The Plan denied your request. The Plan says the records did not support the medical necessity required to approve the request for skilled nursing level of care.The Plan must follow Medicare rules. The rules say that Medicarepays for care in a SNF when the four factors listed above 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 the continued SNF services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 continued SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on June 17, 2019.
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 physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted 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 drug testing rendered to the enrollee on June 17, 2019.