Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor sensor for the enrollee.
You asked the Plan to pre-approve the sensor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of blood glucose testing.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the sensor. Our reviewer says that the requested sensor is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to be a diabetic who takes a mixture of oral and injectable medications, including insulin. The enrollee's insulin doses appear to be fixed, rather than on a sliding scale. The enrollee does not test her blood sugars regularly, because she is afraid of needles. Even if the enrollee were testing her blood sugars regularly, it does not appear that these values would be used by the enrollee to self-adjust her insulin medications multiple times a day. Therefore, the requested CGM is not shown to be medically necessary or 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 the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor sensor for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 11, 2019 by an out of network provider.
You asked the Plan to pay for X-Ray examination. You say that you are appealing. 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 and the referring physician is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on September 11, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services
for the enrollee.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee
does not meet Medicare criteria for SNF care. The enrollee's needs can be met at a lower level of care such as a
long term care facility or hospice.
The Plan must follow Medicare rules. The rules say that Medicare pays 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 SNF services. Our reviewer says
that daily skilled services are not medically necessary. Our physician reviewer found the enrollee has a history
of CVA, PNA, skin cancer, CKD, colitis, embolic stroke, HLD, HTN, IDA, NSTEMI, thyroid disease and
seizures. The enrollee underwent PEG placement and is tolerating tube feeds. He is on a vent mask with
oxygen saturation of 100%. He is not following any simple commands and is afebrile. His overall prognosis is
noted to be poor and comfort measures were highly recommended and the family would like to continue
medical treatment and hospice would be a reasonable consideration. There are no documented current skilled
nursing needs. He is currently dependent with mobility and activities of daily living. The records do not support
that the enrollee needs daily physical therapy and occupational therapy. There are no noted daily skilled
complex nursing needs and no noted daily therapy needs. The enrollee is unable to follow commands. Based on
available records, the enrollee does not meet criteria for coverage of SNF services.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve an admission for skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser fungal treatment.
You asked the Plan to pre-approve these services. You say that you have onychomycosis of all 10 toenails. The
Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the requested laser treatment for
onychomycosis is considered experimental/investigational in nature. More studies are needed before it can be
widely accepted as the standard of care. The services are therefore not reasonable or medically necessary at this
time.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve laser fungal treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered to the enrollee on August 29, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that modifier -RR must be billed for durable medical equipment that is rented. We looked at the file and Medicare rules. The file shows that procedure code E0745 (neuromuscular stimulator) was billed with modifier -NU. This modifier is inappropriate for the services at issue, as the equipment was a rental and requires modifier -RR. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator rendered to the enrollee on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the chiropractic services. The Plan denied your request. The Plan says the services are available in-network.
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 pre-approve 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on September 19, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because you saw your primary care physician not a specialist. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment a specialist office visit. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on September 19, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (99153 and 99152) provided on May 9, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment for CPT code 99153 is included in the payment to the facility and CPT code 99152 cannot be verified because the record did not include documentation of an independent trained observer.
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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service).
The CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. We find that CPT codes 99153 and 99152 are not supported in the record. Specifically, 99153 is a "technical only" code and Medicare considers that the independent trained observer represents an expense to the facility and may only be billed by the facility. Additionally, the record does not include documentation of an independent trained observer to verify code 99152. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153 and 99152) provided on May 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.
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. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee tried and failed Zoledronic acid or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found the enrollee's condition does not meet step therapy criteria for Prolia. 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a dual-energy x-ray for a bone density study (77080) provided on August 23, 2019.
You asked the Plan to waive the coinsurance for a dual-energy x-ray. You say that there should not be a coinsurance for a bone density test and you do not intend to pay it. The Plan denied your request. The Plan says outpatient diagnostic tests with an out-of-network provider have a 40% coinsurance.
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% coinsurance for outpatient diagnostic tests with an out-of-network provider. You have been asked to pay a 40% coinsurance for a dual-energy x-ray. This service falls within the outpatient diagnostic tests with an out-of-network provider benefit category under radium and isotope therapy including technician materials and supplies (the allowable amount of $38.54 x 40% = $15.42). 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 for a dual-energy x-ray for a bone density study (77080) provided on August 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis (72195).
You asked the Plan to pre-approve an MRI of the pelvis. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity cannot be established without the results of prior imaging.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an MRI of the pelvis. Our reviewer says that an MRI of the pelvis is not medically necessary at this time. Our physician reviewer found the documentation did not include the results of the computed tomography and ultrasound. These imaging results must be presented to show whether an MRI is necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the pelvis (72195).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Harvoni.
You asked the Plan to pre-approve Harvoni. The Plan denied your request. The Plan says this is not covered under your Part B benefits.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Harvoni.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September 27, 2019.
You asked the Plan to waive the copayment for an urgent care visit. You say that you disagree with the charges because the staff could not treat your wound and you had to go to the emergency room. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for an urgent care visit. An urgent care visit falls within the urgently needed 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 an urgent care visit provided on September 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy provided on September 17, 2019.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that you did not have any signs or symptoms prior to your colonoscopy. You say you were told there can be discrepancies from the Cologuard test and the actual colonoscopy. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for freestanding Ambulatory Surgical Center. You have been asked to pay a $300 copayment for the diagnostic colonoscopy. The diagnostic colonoscopy falls within the "Outpatient hospital services" benefit category. The medical record shows the colonoscopy was ordered due to an abnormal Cologuard test. Therefore, the colonoscopy is diagnostic in nature.
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 diagnostic colonoscopy provided on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percocet.
You asked the Plan to pre-approve Percocet. The Plan denied your request. The Plan says this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Percocet.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance and pay for surgical implantation of a neurostimulator and self-administered drugs provided on July 26, 2019.
You asked the Plan to waive the coinsurance and pay for outpatient surgery and self-administered drugs. You say that the Plan should reimburse you for these costs. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct. The Plan also says that they have denied payment for self-administered drugs.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Medicare rules say that Medicare Part B generally does not pay for self-administered drugs. Your contract with the Plan clearly says that you must pay 20% coinsurance for in-network outpatient surgery at an outpatient hospital. The allowed amount of the claim is $20,172.14, resulting in a coinsurance obligation of $4,013.45. The Plan also denied payment for self-administered drugs in the amount of $104.90, because these drugs are not covered by Medicare Part B but may be covered by a Medicare Part D prescription drug plan. Your total responsibility for this claim is therefore $4,118.35. You have been asked to pay 20% coinsurance for outpatient surgery and self-administered drugs. outpatient surgery and self-administered drugs falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 and pay for surgical implantation of a neurostimulator and self-administered drugs provided on July 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alirocumab.
You asked the Plan to pre-approve Alirocumab. The Plan denied your request. The Plan says this medication is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Alirocumab.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on July 11, 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 procedure codes 93320 and 93325 are 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 93320 is Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete. The definition of code 93325 is Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography). We find that CPT codes 93320 and 93325 are not supported in the medical record. Specifically, these codes are add-on codes that were not billed with a required primary procedure code. 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 services rendered to the enrollee on July 11, 2019.