Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for paravertebral facet joint nerve destruction (64636) provided on August 7, 2019.You asked the Plan to pay forparavertebral facet joint nerve destruction. You say that the records support the services billed.The Plan denied your request. The Plan says that this code is not supported.The Plan must follow Medicare rules. Medicare rules say thatproviders must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 64636 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure).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 paravertebral facet joint nerve destruction. Our reviewer says that 2 units of CPT code 64636 are supported by the medical record. Our physician reviewer found the record states that the facet joint levels treated were L3-L4, L4-L5, and L5-S1. The record also states that 2 lesions were treated at each faced joint level. The record supports that 2 additional facet joint levels, L4-L5 and L5-S1, after the initial level (L3-L4), were destroyed by a neurologic agent. According to CPT rules, the levels treated were reported correctly.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of paravertebral facet joint nerve destruction have been met.Therefore, we decided that the Plan has to pay forparavertebral facet joint nerve destruction (64636) provided on August 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Jitterbug cell phone with a personal emergency response system button.You asked the Plan to pre-approvea Jitterbug cell phone. You say that you are afraid to go out of the house because the life alert is not operable outside the house.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvea Jitterbug cell phone with a personal emergency response system button.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to "the beneficiary"  by "the hospital" on July 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the enrollee was on hospice.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 beneficiary" 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 forthe services rendered to "the beneficiary" by "the hospital" on July 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordebridement of subcutaneous tissue (11042) provided on August 21, 2019 by out of network provider, "the doctor".You asked the Plan to pay fordebridement of subcutaneous tissue. You say that medically necessary services were provided on request of the MedicalDirector. You say that the services were provided prior to obtaining authorization to avoid delay in care which could result in wound complications.The Plan denied your request. The Plan says the member's plan allows for out-of-network services and payment if the Plan authorizes the service, and/or if it is delivered in an emergency setting, and/or if there are no in-network providers available for these services. The Plan also says that these services were not urgent or emergent and records do not reflect nor support that emergency wound care was provided and needed.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 fordebridement of subcutaneous tissue (11042) provided on August 21, 2019 by out of network provider, "the doctor".
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveGel-One (J7326).You asked the Plan to pre-approveGel-One. You say that this should be covered because you cannot afford your copayment for therapy.The Plan denied your request. The Plan says that you have not tried andfailed three months of conservative therapy.The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy is considered medically necessary when all of the above listed criteria are met.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 Gel-One. Our reviewer says that the criteria for coverage of Gel-One have been met. Our physician reviewer found your clinical diagnosis of left knee osteoarthritis is supported by radiographic evidence of left knee joint space narrowing and marginal osteophytes. There is no evidence to suggest an alternate pain generator. You have failed to achieve adequate relief withlong-term (greater than 3 months) conservative treatment including home exercise, bracing, and topical pain medication. You are unable to take NSAIDs due to allergy and have failed to adequately respond to prior corticosteroid injections. There is no evidence of clinical effusion to support an aspiration. Therefore, the request for Gel-One injection to the left knee meets Medicare coverage criteria and is considered medically reasonable and 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 Gel-One have been met.Therefore, we decided that the Plan has to pre-approveGel-One (J7326).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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe physical therapy services to be provided by an out of network provider.You asked the Plan to pre-approvethe physical therapy services. You say that you have gone to the requested provider in the past and you would like to keep going to the requested provider.The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The plan states there are equally qualified in-network physical therapy specialists available to you that can provide the care and treatment you are requesting.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 haveto pre-approvethe physical therapy services to be provided by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe specialist office visit you received on July 30, 2019.You asked the Plan to waive the copay forthe office visit. You say that you were informed that a copay was not collected for a follow-up.The Plan denied your request. The Plan says the claim for service was processed 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 $50 copay for services in a specialist office. You have been asked to pay a $50 copay for the office visit. The visit falls within the physician 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 waivethe copay forthe specialist office visit you received on July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent injection.You asked the Plan to pre-approve Praluent injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not a covered 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-approvePraluent injection.Benefits for Praluent injectionmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from April 3, 2019 to April 26, 2019.
You asked the Plan to pay for the home health services. You say that there is nothing wrong with the claim and you feel that payment should be made for the services. The Plan denied your request. The Plan says the provider failed to include a line item with the required Q-code to signify the location in which the services were rendered.
The Plan must follow Medicare rules. Medicare rules say that one of three Q-codes must be reported as a separate line item for home health claims to signify the location in which services were provided. In this case, the claim does not have a line item with a Q-code. This means that the claim is not correctly billed. Therefore, we decided that the Plan does not have to pay for the home health services provided from April 3, 2019 to April 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe knee brace provided on September 28, 2019.You asked the Plan to waive the coinsurance for the knee brace. You say that you are on a fixed income and do not feel that you should have to pay for an item you did not use. The Plandenied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for each external Medicare-covered standard prosthetic device and related supplies. You have been asked to pay $18.82 which is 20% of the allowed amount for the knee brace. The allowedamount is $94.12. ($94.12 x 20% = $18.82). The knee brace falls within the "Prosthetic devices and related 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 coinsurance forthe knee brace provided on September 28, 2019
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 25, 2019 by out of network provider, "the doctor".You asked the Plan to pay forphysical therapy. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the member's primary care physician did not refer the member for these services. The Plan says that no prior authorization was 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 Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on August 25, 2019 by out of network provider, "the doctor".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forelectrodes (A4556).You asked the Plan to pay forelectrodes. You say that this should be paid.The Plan denied your request. The Plan says this processed correctly.The Plan must follow Medicare rules. Medicare rules say that no separate payment is made for CPT codes with a status indicator of P under the fee schedule.We find that CPT code A4556 is not supported in the medical record. Specifically, this code has a status indicator of P. No separate payment can be made for it under the fee schedule. Based on this information, we decided that Medicare rules for coverage of electrodes have not been met.Therefore, we decided that the Plan does not have to pay forelectrodes (A4556).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe oxygen concentrator and portable oxygen concentrator provided on January 18, 2019.You asked the Plan to waive the coinsurance forthe oxygen concentrators. You say that you should not be responsible for the cost.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment.You have been asked to pay a total of $21.30 for the oxygen concentrators.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on September 19, 2019.You asked the Plan to pay for the dental services. You say that the provider is listed as in network on page 1952 of the Plan's website.The Plan denied your request. The Plan says dental services received out of network are not covered. The Plan says that the provider in this case is not a network provider at the location that you saw him. The Plan also says that you received services from this provider at a location other than the one that is specifically listed on the website.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 and the services are listed as covered, they are not covered when you receive the services out of network. The record shows that the address you received the services at is different than the one that is specifically listed on the website.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on September 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiation treatment (77387) provided on July 29, 2019 by out of network provider, "the provider". You asked the Plan to pay forradiation treatment. You say that you would like a review for reconsideration on the bases of medical necessity.The Plan denied your request. The Plan says "the provider" is a non-network provider with the member's health plan, and member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possibleand 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 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 forradiation treatment (77387) provided on July 29, 2019 by out of network provider,"the provider".
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora cataract surgery on September 11, 2019.You asked the Plan to waive the coinsurance fora cataract surgery. You say that you were not informed that you would owe such a high copayment per each cataract surgery.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 20% coinsurance for each outpatient hospital facility visit.You had a cataract surgery at an outpatient hospital on September 11, 2019. The allowed amount is $2,213.36 and 20% of that is $442.67.  You have been asked to pay the total coinsurance amount of $442.67 for a cataract surgery. A cataract surgery falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance fora cataract surgery on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on September 3, 2019.You asked the Plan to pay forthe periodic oral evaluation and prophylaxis. You say that you have been going to this provider for many years. You also say that you thought you would be covered by the Plan to go to this provider.The Plan denied your request. The Plan says these services were rendered by an out-of-network provider.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 covered when they are received out-of-network.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation and prophylaxis provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy (97802 and 97803) provided on July 22, 2019 through August 26, 2019.You asked the Plan to pay for medical nutrition therapy services. You say that you were informed that this was a covered benefit. The Plan denied your request. The Plan says the diagnosis codes in the submitted claim are not payable codes for medical nutrition therapy services.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy (97802 and 97803) provided on July 22, 2019 through August 26, 2019. Your complaint about being informed that this is a covered benefit 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora home visit for the evaluation and management of an established patient (99349) provided on June 7, 2019 to July 9, 2019 You asked the Plan to pay fora home visit. You say that you are asking for a reconsideration based on the lack of options, rejection from the other house call providers in the area and the patients limited mobility. You say that you are still trying to become an in-network provider with the plan. You further say that the loss of all these prior dates of service will cause an immediate shut down of your practice and these patients will be forced to rely on ambulance trips to the emergency roomfor even the most routine of care.The Plan denied your request. The Plan says Medicare says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.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 fora home visit for the evaluation and management of an established patient (99349) provided on June 7, 2019 to July 9, 2019.