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

We decided that the Plan does not have to pay for physician services provided on October 29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 physician services provided on October 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit that you provided on December 17, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says there is no valid referral for this service.
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 services at issue. 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 a domiciliary or rest home visit that you provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided at the tertiary level of care.You asked the Plan to pre-approve consultation visit. You say that you had heart surgery with this provider in the past and would like to continue follow-ups with them.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not need to be treated by this tertiary level of care provider and can be treated by a community level physician instead.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 consultation visit. Our reviewer says that you do not meet the Medicare criteria for treatment at the tertiary level of care. Our physician reviewer found you were noted to have atrial flutter. Atrial flutter is a common condition and trained, board-certified cardiac electrophysiologists handle the management and treatment of this condition routinely. The Plan's recommended community level physician is board-certified in electrophysiology. She meets the training, certification, and standard of care requirements to treat your condition. There is nothing clinically unique about your condition that would require you to be treated at the tertiary level of care 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 consultation visit have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided at the tertiary level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have foot pain and cannot stand for extended periods of time. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc is not approved as step criteria is not met.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone-Acetaminophen 7.5-325mg.
You asked the Plan to pre-approve Hydrocodone-Acetaminophen. You say that the medication is medically necessary. The Plan denied your request. The Plan says coverage for this type of drug is not available under the Part B medical benefit.
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 Hydrocodone-Acetaminophen 7.5-325mg.
Benefits for Hydrocodone-Acetaminophen may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the aspirations provided on December 23, 2019 and December 26, 2019.
You asked the Plan to waive the copayment for the aspirations. You say that it is your understanding that all follow up visits after surgery are included as part of the initial surgery charges. You say that both visits should be recoded. The Plan denied your request. The Plan says the copayments applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $400 copayment for in-network, Medicare-covered outpatient hospital surgery services. You have been asked to pay a total of $680.62 for the aspirations.
The aspirations fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The aspirations are considered a surgical procedure that were provided by the hospital. 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 aspirations provided on December 23, 2019 and December 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous Reclast (J3489).
You asked the Plan to pre-approve IV Reclast. You say that the IV Reclast is medically necessary. The Plan
denied your request. The Plan says a trial of oral bisphosphonates is required before alternatives including
Intravenous Reclast can be considered.
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 IV Reclast. Our reviewer says that rules
for coverage are not met. Our physician reviewer found the record shows no reason the plan preferred step
therapy drug would be contraindicated or ineffective for this patient. There was no trial of the plan preferred
drugs documented in the record.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IV Reclast have not been met. Therefore, we decided that the Plan does not
have to pre-approve intravenous Reclast (J3489).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on December 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab services. You say that you would like this claim reprocessed and approved for payment. 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 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 lab services provided on December 18, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic services rendered on November 12, 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 code 95999 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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record. Specifically, the file shows that Train of Four testing was performed and there is a more appropriate code for these services. 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 diagnostic services rendered on November 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee is medically unstable for SNF transfer.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 SNF services. Our physician found that the enrollee does not require skilled nursing services or skilled therapy services in a SNF at this time. The documentation does not support that the enrolleeis stable enough to transfer to a SNF for rehabilitation. The enrolleecannotfully participate in daily therapy at this time. As a practical matter,at this time,the enrolleerequires continued medical management in her current acute care setting and does not require SNF level skilled nursing or skilled therapy 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the charges for the medical services provided from January 19, 2019 to October 28, 2019.
You asked the Plan to adjust the charges for the medical services. You say that you do not agree with the amount that this facility is billing you. The Plan denied your request. The Plan says the facility has applied the correct copayments to 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). The contract says that enrollees must pay the cost sharing described above in the Medicare Rules section. In this case, we reviewed the documentation and the claims provided during this period. You have been asked to pay a $275 copayment for the one day of inpatient hospital care provided on January 19, 2019, which is correct according to your contractual cost sharing. You have been asked to pay a $65 copayment for each of the three ER visits provided on March 29, 2019, June 29, 2019, and October 11, 2019, which is correct according to your contractual cost sharing. On September 17, 2019, you were provided with a CT scan and an echocardiogram. You were asked to pay $150 for the echocardiogram, which is correct according to your contractual cost sharing, and $120.75 for the CT scan, since the allowed amount is less than the applicable $150 copayment. From September 26, 2019 to September 30, 2019, you received daily outpatient IV infusions, for which you have been asked to pay $200.81 for each visit. This is correctly applied because the allowed amount for these visits is less than the $250 copayment applicable to outpatient hospital visits. On October 4, 2019 and October 28, 2019, you were seen in the outpatient hospital and were asked to pay $87.04 for these visits as the allowed amount was less than the applicable $250 copayment. You were seen in the outpatient hospital on October 28, 2019, for which the $250 copayment was applied, which is correct according to your contractual cost sharing. On October 23, 2019, you received a nuclear stress test, for which you have been asked to pay $150 which is the correct copayment for diagnostic imaging. Our review of the services rendered confirms that you have been asked to pay the correct amount based on your contract with the Plan for the services rendered. 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 adjust the charges for the medical services provided from January 19, 2019 to October 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on February 27, 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 not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 testing rendered on February 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is necessary due to the enrollee's fall risk. The Plan denied your request. The Plan says the documentation does not show this is medically necessary.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided this patient does not require skilled nursing services. While she requires skilled therapy services, she does not need them on a daily basis. She also does not require the services on an inpatient basis, in a skilled nursing facility setting. Services in a long-term care facility on a part time basis or in the home with home health services appears appropriate 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visits provided on March 4, 2020 and March 5, 2020 by an out of network (OON) provider.You asked the Plan to pay foroffice visits. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained for these services.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 Planto pay for these items/services.Therefore, we decided that the Plan does not have to pay foroffice visits provided on March 4, 2020 and March 5, 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 catheter supplies to be provided by an out of network provider.
You asked the Plan to pre-approve catheter supplies. You say that it is no cost to you to use the out-of-network supplier. The Plan denied your request. The Plan says you have no out-of-network benefits and there are 20 in-network providers within a 50-mile radius of your zip code.
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 care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the catheter supplies to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair. You asked the Plan to pre-approve a power wheelchair. You say that you need a power wheelchair. The Plan denied your request. The Plan says you are ambulatory with a cane and there is no physician order. The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD being requested. There is no physician order, home assessment, or face-to-face documentation. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on August 21, 2019.
You asked the Plan to pay for the moderate sedation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 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 code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 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 the moderate sedation services provided on August 21, 2019.