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

We decided that the Plan does not have to pre-approve Durolane 60 mg/3 mL injection (J7318).
You asked the Plan to pre-approve Durolane. You say that the service is medically necessary for the enrollee.
The Plan denied your request. The Plan says rules for step therapy have not been met.
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 Durolane. Our reviewer says that the
service requested is not medically necessary. Our physician reviewer found the enrollee has not trialed one
viscosupplemental treatment such as Orthovisc and Monovisc. Further, the documentation does not outline
contraindications or reasons these medications were not considered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have
to pre-approve Durolane 60 mg/3 mL injection (J7318).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services (G0299, G0151, Q5001) provided on June 29, 2020 to July 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forhome health services. You say that the services were medically necessary.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-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 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 home health services (G0299, G0151, Q5001) provided on June 29, 2020 to July 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient office visit (99213) provided August 14, 2020.You asked the Plan to waive the copayment forthe office visit. You say that you arenot supposed to be charged for a wellness exam. You disagree with the copay. You did not do anything outside of a normal wellness exam.The Plan denied your request. The Plan says this claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $10 copayment for each primary care doctor office visit for Medicare covered services.You have been asked to pay $10 copayment for the office visit. The office 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 haveto waive the copayment forthe outpatient office visit (99213) provided August 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forneedle electromyography provided on September 11, 2019.You asked the Plan to pay forneedle electromyography (95861). You say that the Plan should pay this claim.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the services.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 95861 is Needle electromyography; 2 extremities with or without related paraspinal areas. We find that CPT code 95861 is not supported in the medical record. Specifically, the documentation submitted does not indicate that the procedure was performed.Based on this information, we decided that Medicare rules for coverage of needle electromyography (95861) have not been met.Therefore, we decided that the Plan does not have to pay forneedle electromyography provided on September 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora prefabricated and off-the-shelf lumbar-sacral orthosis with rigid anterior and posterior panels (L0650) provided.

You asked the Plan to pay for the lumbar-sacral orthosis. The Plan denied your request. The Plan says there are no supporting office records for the device in dispute.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that providers must furnish sufficient information to determine whether payment is due and the amount of payment.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis provided on May 6, 2020.
You asked the Plan to pay for digital breast tomosynthesis. 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 procedure code is not
valid for Medicare purposes and is not payable.
The Plan must follow Medicare rules. Medicare rules say that procedure code 77062 is not valid for Medicare
purposes and is not payable.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have
to pay for digital breast tomosynthesis provided on May 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses provided to the enrollee on February 13, 2020.
You asked the Plan to pay for the orthoses. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support the service billed, as the documentation submitted did not include a valid physician order.
The Plan must follow Medicare rules. Medicare rules say that DME must be provided with a physician order. There is no evidence of a valid physician order in this case. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. Therefore, we decided that the Plan does not have to pay for orthoses provided to the enrollee on February 13, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for assisted surgery services provided on October 17, 2019.
You asked the Plan to pay for these services. You say that you were unaware of any services provided by a surgery assistant. The Plan denied your request. The Plan says that the claim submitted by the provider included assistant surgical services that are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. You received services from an out of network provider, which is allowed by your Plan contract. There is no indication that you were given prior notice that an assistant surgeon would be used during the procedure. You would have no control over the services being billed or how they were billed or what codes were used. The Plan has not substantiated that its denial was correct. Technical denials due to coding errors are not the responsibility of an enrollee. Therefore, we decided that the Plan has to hold you harmless for assisted surgery services provided on October 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on August 25, 2020.
You asked the Plan to waive the copayment for podiatry services. You say that you disagree with the charges because you did not have relief after all of the visits. 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 $25 copayment for podiatry services. You have been asked to pay a $25 copayment for podiatry services. Podiatry services fall within the podiatry 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 podiatry services provided on August 25, 2020.
We note your complaint that you did not have relief from the pain. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora WATS 3D biopsy (88361, 88312, 88305, 88104) provided on May 12, 2020.You asked the Plan to pay fora WATS 3D biopsy. You say that this has been found to be safe and effective.The Plan denied your request. The Plan says this is experimental.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 pay for a WATS 3D biopsy. Our reviewer says that the WATS 3D biopsy at issue is not considered medically reasonable and necessary in this case. Our physician reviewer found guidelines suggest only conditionally that WATS-3D be reserved for cases of known or suspected Barrett's esophagus. The medical records do not support the high likelihood of Barrett's esophagus, and thus does not meet the spirit of ASGE guidance relative to medically necessary use of WATS-3D 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 a WATS 3D biopsy have not been met.Therefore, we decided that the Plan does not have to pay fora WATS 3D biopsy (88361, 88312, 88305, 88104) provided on May 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total hip replacement (27130). 
 
You asked the Plan to pre-approve the total hip replacement. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Hip Replacement surgery is covered when 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 the total hip replacement. Our reviewer 
says that the total hip replacement is not medically necessary. Our physician reviewer found there is no 
documentation of adequate conservative measures for hip pain to include physical therapy. 
 
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 total hip replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total hip replacement (27130).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe immunohistochemistrytesting provided on July 27, 2020, billed with one unit of 88341-26 and two units of 88341-26-59.You asked the Planto pay forthe pathology testing as billed. You say that this is medically necessary testing.The Plandenied your request. The Plansaysthis was not billed with a valid primary code.The Plan must follow Medicare rules. Medicare rules say that Type I add-on codes must be billed with a primary code from a specific list. In this case, code 88341 is a Type I add-on code for which the only allowed primary code is 88342. As 88342 was not billed on this claim, the use of 88341 is not appropriate.Therefore, we decided that the Plandoes not haveto pay forthe immunohistochemistry testing provided on July 27, 2020,billed with one unit of 88341-26 and two units of 88341-26-59
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe molecular pathology services provided on March 18, 2020 billed with codes 88361-59, 88312-XP, 88305-XP, and 88104-59.You asked the Planto pay forthe molecular pathology services. You say that this was denied for not being medically necessary; however, the WATS 3D diagnostic platform is recommended by the American Society of Gastrointestinal Endoscopy.The Plandenied your request. The Plansaysthe professional interpretation was furnished in the same payment locality from where the TC was furnished. We find that the Medicare rule for payment of this claim has not been met as the professional interpretation of a diagnostic test must be separately billed with modifier-26 by the interpreting physician.The Plan must follow Medicare rules. Medicare rules say that the TC of physician pathology services cannot be paid under the Physician Fee Schedule when these services are provided to a hospital outpatient. In this case, the Place of Service code was reported as 22, which means that the enrollee was a hospital outpatient. The global service for these codes was billed, meaning both the professional and TC. Only the professional component can be paid for these services when rendered to a hospital outpatient.Therefore, we decided that the Plandoes not haveto pay forthe molecular pathology services provided on March 18, 2020 billed with codes 88361-59, 88312-XP, 88305-XP, and 88104-59
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided from July 14, 2020, to July 26, 2020.You asked the Plan to pay forthe SNF services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says since the enrollee was discharged from the SNF on July 13, 2020, additional coverage is not at issue.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 looked at the file and Medicare rules. It appears from the case record that the enrollee was discharged from the SNF on July 13, 2020. Therefore, the additional dates of service from July 14, 2020, to July 26, 2020 cannot be covered. Based on thisinformation, 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 pay forthe skilled nursing facility (SNF) services provided from July 14, 2020, to July 26, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay foran outpatient visit provided by an out-of-network provider on September 2, 2020.You asked the Plan to pay foran outpatient visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says that prior authorization was not obtained.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. A readable 2020 EOC was not sent in with this case file.Therefore, we decided that the Plan has to pay foran outpatient visit provided by an out-of-network provider on September 2, 2020.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe scaling in presence of generalized gingival inflammation (D4346) provided on February 18, 2020.You asked the Plan to pay forthe scaling in presence of generalized gingival inflammation. You say that you repeatedly asked the dentist if the x-rays that they were taking would be covered. You say that the dentist advised that each service was necessary and therefore would be covered. You say that the cleaning was extremely painful and aggressive. You say that you paid $35 for the services on the date of service in this case and for services you received on March 9, 2020, and were advised you would not owe any more.The Plan denied your request. The Plan says scaling in presence of generalized gingival inflammation is not listed as a covered service.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe scaling in presence of generalized gingival inflammation (D4346) provided on February 18, 2020.
Your complaint about the aggressive cleaning is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.The decision in this case does not address your concerns for the date of service March 9, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ER visit provided on July 19, 2019.You asked the Plan to waive the copayment forthe ER visit. You say that the doctor required the biopsy for your cancer treatment. You say that insurance should cover this procedure.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 $90 copayment for emergency services in an emergency room.You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. 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 forthe ER visit provided on July 19, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a participating provider on December 30, 2019.You asked the Planto waive the coinsurance for durable medical equipment. You say that you do not agree with these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.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 20% coinsurance for durable medical equipment. You have been asked to pay a 20% coinsurance of the allowed amount for durable medical equipment. The total allowed amount is $419.55. The total amount you are being asked to pay is $83.91 ($419.55 x 20% = $83.91). Durable medical equipment falls within the durable medical equipment 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 for durable medical equipment provided by a participating provider on December 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe personal protective equipment (D1999) provided on July 9, 2020.You asked the Plan to pay forthe dental service. You say that 2 visits per year are covered at 100%. You say that the $10 should be covered or you would like to know where you can go so that the full visit will be covered. You also say that you have spent many hours on the phone, being disconnected and passed around trying to resolve this issue.The Plan denied your request. The Plan says the personal protective equipment is not listed as a covered service. The Plan says that the American Dental Associates (ADA) allows dentists to charge a fee to their patients for infection control procedures and personal protective equipment due to the extraordinary circumstances dentists and their patients face as they navigate the COVID pandemic. The Plan also says that the fee amount the dentist can charge is not set by the ADA or a third-party payer.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe personal protective equipment (D1999) provided on July 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on April 30, 2020.You asked the Plan to pay forthe ambulance services. You say that you did not request for this service.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 April 30, 2020. 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 forthe ambulance services provided on April 30, 2020