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

We decided that the Plan does not have to pay for the insertion of intra-aortic balloon assist device (33967) and related services (C1887, C1725, C1769, C1887, C1894, U0003, U0005, 87426, 80053, 85025, 36415, 83880. 84484, 85347, 85730, 85610, 71045, 99285, 92920, Q9967, J1644, J2001, J3010, J2250, 93005) provided on March 7, 2021.

You asked the Plan to pay for the insertion of intra-aortic balloon assist device and related services. You say that this member was treated before transferring to another facility. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. Medicare does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). Medicare also does not pay for all other services on the same day as the "inpatient only" procedure. 

The service at issue in this appeal was billed with CPT code 33967. This code is listed with a status indicator of "C" on Addendum B of the 2021 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. This code and the related services were billed on an outpatient hospital bill type. Therefore, we decided that the Plan does not have to pay for the insertion of intra-aortic balloon assist device (33967) and related services (C1887, C1725, C1769, C1887, C1894, U0003, U0005, 87426, 80053, 85025, 36415, 83880. 84484, 85347, 85730, 85610, 71045, 99285, 92920, Q9967, J1644, J2001, J3010, J2250, 93005) provided on March 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 5, 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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on March 22, 2021.
You asked the Plan to pay for the dental services. You say that at the time, there were no dentists in your area that were accepting new patients. You say that you still had to wait 2 months for an appointment. You also say that you would like to continue seeing this provider. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that dental services performed out of network are not covered.
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, dental services performed out of
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and the panoramic x-ray (D0330) provided on March 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on March 11, 2021.
You asked the Plan to pay for physical therapy. You say that the patient was seen for physical therapy for left shoulder pain. You say that the authorization should be approved, and the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but not 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 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 physical therapy provided by an out-of-network provider on March 11, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the ultrasound provided on December 30, 2020.

You asked the Plan to adjust the copayment for Ultrasound, scrotum and contents (76870). You say that the Plan contends the service was provided in a free-standing facility but that is not defined in any policy document. The Plan denied your request. The Plan says you were charged the copayment 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 $160 copayment for Other Outpatient Diagnostic Tests. 

You have been asked to pay a $109.44 copayment for Ultrasound, scrotum and contents (76870). Ultrasound, scrotum and contents (76870) falls within the Other Outpatient Diagnostic Tests benefit category. This is the allowable amount for this procedure, which is less than your required copayment. 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 adjust the copayment for the ultrasound provided on December 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 11, 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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on January 25, 2021.
You asked the Plan to pay for the topical application of fluoride varnish. You say that your dental provider stopped using the fluoride code D1208 prior to this date of service. You also say that you feel this service should be covered. The Plan denied your request. The Plan says this service code (D1206) is not covered.
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 for the topical application of fluoride varnish (D1206) provided on January 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transportation (A0428) provided on November 25, 2020.

You asked the Plan to pay for the ground mileage and ambulance transportation. You say that the enrollee was admitted to hospice after the ambulance ride and you believe these services should be covered. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transportation (A0428) provided on November 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9367) provided to the enrollee from January 22, 2021 to January 28, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The denied code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9367) provided to the enrollee from January 22, 2021 to January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82247, 82947, 84460) provided on February 3, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 had network providers available who could have provided 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 laboratory services (82247, 82947, 84460) provided on February 3, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has Crohn's disease. She has not tried and failed the Plan's required drugs, Remicade or Inflectra and Stelara. The records do not show that the required drugs would be contraindicated or less effective; therefore, Entyvio is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has left knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81407, 81408) provided January 22, 2021.
You asked the Plan to pay for the lab tests. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment panels. We looked at the file and Medicare rules. The services performed are non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab tests have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81407, 81408) provided January 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary for psoriasis. The Plan denied your request. The Plan says this is not medically necessary.

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 based on the medical records provided, the enrollee has not tried and failed the plan's required step therapy drugs. There is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

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 Ilumya for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on January 11, 2021, billed with two units of 88323 and one unit of 88342.

You asked the Plan to pay for the pathology services as billed. You say that these services were medically necessary and billed correctly. The Plan denied your request. The Plan says more than one unit of 88323 is not payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. The rules also say that when an NCCI edit exists for a code pair, only the Column 1 code is payable unless a clinically appropriate modifier is used. 

In this case, the MUE for CPT code 88323 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Only one unit of this code is payable. In addition, code 88342 is a Column 2 code is relation to 88323. No modifier was reported to allow for separate payment of this code. Based on this information, we decided that Medicare rules for coverage of the pathology services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on January 11, 2021, billed with two units of 88323 and one unit of 88342.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, binaural (V5261) provided January 22, 2021.

You asked the Plan to pay for the hearing aids. You say that you were not aware that you had to use one of the Plan's network providers in order for the hearing aids to be covered. The Plan denied your request. The Plan says the hearing aids were purchased out-of-network and therefore are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from one of the plan's hearing network providers. 

We looked at the file and the Plan's rules. In this case the hearing aids were purchased from a provider who is not part of the Plan's hearing network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aid, digital, binaural (V5261) provided January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 15, 2020, through December 16, 2020.

You asked the Plan to pay for inpatient hospital care. You say that the claim was partially paid amounting to $8,470.29 and the expected amount is $43,472.14. You state to please process accordingly. The Plan denied your request. The Plan says there are no medical records to support medical necessity for these additional charges.

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 inpatient hospital care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that as of December 16, 2020, the enrollee had completed antibiotics for left empyema methicillin-resistant Staphylococcus aureus (MRSA) infection, the enrollee's diarrhea had resolved, their paroxysmal atrial fibrillation (PAF) was stable and the enrollee was off Amiodarone due to prolonged QT and the enrollee's delirium had cleared. The enrollee was participating in physical therapy and awaiting disposition. As of December 16, 2020, the enrollee did not require or receive any inpatient diagnostic studies or therapeutic interventions. The review indicates that the enrollee did not require inpatient level of care services after December 16, 2020. 

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 hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from November 15, 2020, through December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the testosterone injection provided on March 26, 2021 by an out-of-network provider.

You asked the Plan to pay for the injection, testosterone cypionate, 1 mg (J1071) and therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (96372). You say that you would like the Plan to approve the authorization and reprocess the claim. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.

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 had network providers available who could have provided the services at issue in this appeal. 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 the testosterone injection provided on March 26, 2021 by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy, total parenteral nutrition (tpn) (S9367) provided from January 1, 2021, to January 21, 2021.
You asked the Plan to pay for the home infusion therapy. You say that the correct CPT (current procedural terminology) code that was billed for these charges. You also say that you feel these services should be paid. The Plan denied your request. The Plan says the claim was billed with a CPT code which is invalid for usage with Medicare. The Plan also says that we find that Medicare rule for payment of this claim has not been me.
The Plan must follow Medicare rules. Medicare rules say that services with a Status Code of "I", indicate that the code is not valid for Medicare purposes and therefore is not payable. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy, total parenteral nutrition (tpn) (S9367) provided from January 1, 2021, to January 21, 2021.