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

We decided that the Plan does not have to waive the copay for the CT scan you received on October 22, 2019.You asked the Plan to waive the copay for the CT scan. You say that you required services quickly, and were told the bill would be covered.The Plan denied your request. The Plan says the copay was applied based on your plan benefits.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 copay per day for Medicare-covered diagnostic radiology services. The file shows that you received a CT scan of the abdomen and pelvis. You were charged $279.60 for the scan. Because the amount is less than the $325 copay, you were charged the lesser amount.  The CT scan falls within the outpatient diagnostic tests 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 copay for the computed tomography (CT) scan you received on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.
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 27507 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 27507 is open treatment of femoral shaft fracture with plate/screws, with or without cerclage. We find that CPT code 27507 is not supported in the medical record. Specifically, the operative report does not indicate that open treatment of a femoral shaft fracture was performed. 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.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the insulin injection, per 5 units, provided from September 25, 2019 to September 26, 2019.You asked the Plan to pay for the insulin injections. You say that the enrollee did not want the insulin injections. You say that the hospital staff advised that the enrollee did not have a choice. You also say that the enrollee was not informed that they would be charged for the insulin.The Plan denied your request. The Plan says the insulin injections are considered to be self-administered. The Plan says self-administered drugs are not covered under your medical Part B plan.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 pay for the insulin injection, per 5 units, provided from September 25, 2019 to September 26, 2019.Benefits for the insulin injections 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99217) provided on November 6, 2019.You asked the Plan to pay for discharge day management. You say that this service should not be bundled into other services.The Plan denied your request. The Plan says the corresponding observation stay has not been reported.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 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).We find that CPT code 99217 is not supported in the medical record. Specifically, this code is for discharge services that were not provided on the initial date of observation status. Observation care was not billed for this stay, nor do the records demonstrate that the date the patient was discharged was not the initial date of observation status. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met.Therefore, we decided that the Plan does not have to pay for discharge day management (99217) provided on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 27, 2019.You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 laboratory 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 laboratory services provided on November 27, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for observation discharge services (99217) provided on November 2, 2019.You asked the Plan to pay for the observation discharge. You say that you would like reconsideration because this service was billed correctly.The Plan denied your request. The Plan says a qualifying initial or subsequent observation care service, or another service resulting in an observation stay has not been reported so the discharge service is denied.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 99217 is not supported in the record. Specifically, it is inappropriate to bill observation discharge services without a qualifying initial or subsequent observation service code. Based on this information, we decided that Medicare rules for coverage of the observation discharge have not been met.Therefore, we decided that the Plan does not have to pay for observation discharge services (99217) provided on November 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ambulatory lumbar traction device.

You asked the Plan to pre-approve an ambulatory lumbar traction device. You say that  The Plan denied your request. The Plan says that Medicare criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that traction equipment is covered if patient has orthopedic impairment requiring traction equipment that prevents ambulation during the period of use. 

You are requesting ambulatory traction equipment. Therefore, we decided that the Plan does not have to pre-approve an ambulatory lumbar traction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2331) provided on December 16, 2019.You asked the Plan to pay for the dental service. You say that all dental work is covered by your plan.The Plan denied your request. The Plan says you do not have a supplemental benefit that will cover this service. The Plan also says that the provider in this case is not a network provider.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay for the filling (D2331) provided on December 16, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided.
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that you feel you should not be responsible for this cost sharing amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic hearing exam on the date of service at issue in this appeal. The Plan says the correct copayment has applied per your contract with the Plan.
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 $10 copayment for Hearing Services. We looked at the file, the Plan contract and Medicare rules. The file shows you received a diagnostic hearing exam. You have been asked to pay a $10 copayment for the diagnostic hearing exam. The diagnostic hearing exam falls within the Hearing 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 diagnostic hearing exam provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the venous access procedure provided on December 5, 2019.You asked the Plan to waive the copayment for the venous access procedure. You say that you weren't informed of any additional charges. You say that you are not responsible for this. The Plan denied your request. The Plan says the copayment 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 $295 copayment for Medicare covered surgery or other services provided to you at an outpatient hospital.You have been asked to pay $127.87, which is less than the standard $295 copayment for the venous access procedure. The venous access procedure falls within the "Outpatient Surgery and Other Medical 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 copayment for the venous access procedure provided on December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that both ambulance visits to your home required the EMT responders to give you an IV for treatment. You say that you were unresponsive and they had to stabilize your vitals and get you off of the floor. You stated that the medical treatment was necessary for you to function on your own, and if they had not been present you could have gone into diabetic shock. You say that you believe this was medical attention that was needed to save your life and should be part of your medical coverage. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 2, 2019 and October 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Supartz FX 25mg/2.5ml syringe for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The documentation does not support that Monovisc and Orthovisc (Hyaluronic acid) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve the Supartz FX 25mg/2.5ml syringe for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
You asked the Plan to pre-approve the sensors and transmitter. The Plan denied your request. The Plan says that these items are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the DME benefit are defined as therapeutic CGMs and codes A9276 and A9277 are used to describe the supplies used with a non-therapeutic CGM. We looked at the file and Medicare rules. Based on this information, we decided that you are requesting supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve sensors for use with interstitial continuous glucose monitoring (A9276) and transmitter, external for use with interstitial continuous glucose monitoring (A9277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0625).
You asked the Plan to pre-approve the total electric hospital bed. You say that the electric hospital bed is medically necessary. The Plan denied your request. The Plan says total electric hospital beds are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0625).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on October 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says there is no network deficiency for the services, and alternate network providers were found.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 ordering provider 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 theservices 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 forthe lab services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four monitoring (95937) provided on October 7, 2019.You asked the Plan to pay forthe trainof four monitoring. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says train of four monitoring does not meet the CMS Guidelines of CPT code 95937.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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the record. Specifically, the record indicates that train of four monitoring was rendered which does not meet guideline criteria for CPT code 95937. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four monitoring (95937) provided on October 7, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on October 21, 2019.You asked the Plan to pay for the anesthesia services. You say that the anesthesia services were medically necessary.The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage enrollee on hospice.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.The enrollee ended Medicare Hospice benefits on October 20, 2019. The services in question were provided before the end of that month.Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit, regadenoson injection, stress test and myocardial perfusion imaging provided on October 22, 2019.
You asked the Plan to waive the cost share for the office visit, regadenoson injection, stress test and myocardial perfusion imaging. You say that submitted your bill for review. You say that you are not supposed to pay. The Plan denied your request. The Plan says the cost share 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 $30 copayment for in-network specialist services, 20% coinsurance for chemotherapy drugs and for all other drugs covered under Medicare Part B from an in-network provider, a $75 copayment for in-network diagnostic procedures and tests and a $200 copayment for diagnostic radiology performed by an in-network provider other than your primary care physician. You have been asked to pay a total of $247.38 for the office visit, regadenoson injection, stress test and myocardial perfusion imaging.
Service
Allowed Amount
Standard Cost Share
Member Liability
Office Visit
$115.83
$30
$30
Regadenoson Injection
$236.88
20%
$47.38
Stress Test
$65.74
$75
$45
Myocardial Perfusion Imaging
$509.13
$200
$125
TOTAL:
$247.38
The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The regadenoson injection falls within the "Medicare Part B prescription drugs" benefit category. The stress test and myocardial perfusion imaging fall within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 cost share for the office visit, regadenoson injection, stress test and myocardial perfusion imaging provided on October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health care provided from December 11, 2019 to December 16, 2019.
You asked the Plan to pay for inpatient mental health care. You say that the enrollee needed to be admitted for his well-being. The Plan denied your request. The Plan says this was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 pay for inpatient mental health care. Our reviewer says that the services at issue do not meet Medicare criteria for coverage. Our physician reviewer found it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient mental health care provided from December 11, 2019 to December 16, 2019.