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

We decided that the Plan does not have to pay for laboratory services provided on September 18, 2020.You asked the Plan to pay for the laboratory services. ThePlan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 September 18, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services (A0427 and A0425) provided on August 29, 2020.You asked the Plan to pay forthe ambulance services. You say that you would like reconsideration because the member received two transports on the same date of service.The Plan denied your request. The Plan says this claim has not been billed correctly.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes A0427 and A0425 are not supported in the record. Specifically, these codes were billed with modifier HH indicating the transfer was from hospital to hospital. The records show that the transport for these services was from the scene to a hospital. HH is not the appropriate modifier to use in this case. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forthe ambulance services (A0427 and A0425) provided on August 29, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory testing provided on June 3, 2020.You asked the Plan to pay forthe laboratory testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The laboratorytesting at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory testing provided on June 3, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora stair glide provided by Acorn Stair Lift on July 23, 2020.You asked the Plan to pay fora stair glide. You say that this is medically necessary.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay fora stair glide provided by Acorn Stair Lift on July 23, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe definitive drug testing provided on July 2, 2020.You asked the Planto pay forthe drug testing. You say that this was correctly billed and should be paid due to medical necessity.The Plandenied your request. The Plansaysthe use of POS code 81 is not supported as it appears that this sample was taken in the office setting.The Plan must follow Medicare rules. Medicare rules say that the POS code for laboratory claims should reflect the location at which the sample was obtained.In this case, the urine sample was obtained on July 2, 2020 in Colorado and received by the lab the next day. As such, POS code 81 is not supported.Therefore, we decided that the Plandoes not haveto pay forthe definitive drug testing provided on July 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray provided on September 29, 2020.You asked the Plan to waive the copayment foran X-ray. You say that you disagree with the charges because you received the X-rays on the same day as an MRI.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 $20 copayment for X-rays. You have been asked to pay a $20 copayment for an X-ray. An X-ray falls 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran X-ray provided on September 29, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the records do not support the ability to tolerate an intensive rehab therapy program.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our physician reviewer found that the enrollee was admitted to the acute hospital for metabolic encephalopathy and was treated for acute kidney injury and urinary tract infection. Her medical conditions are stable. The complexity of hernursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that this enrolleewill be able to fully participate in and benefit from the intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe duplex scan provided on July 21, 2020.You asked the Plan to waive the copayment forthe duplex scan of extracranial arteries (93880). You saythat this was a minor scan so the Plan must have coded it wrong.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 outpatient diagnostic tests. You have been asked to pay a $160 copayment for the duplex scan of extracranial arteries (93880). The provider submitted the claim with the code 93880. The duplex scan of extracranial arteries (93880) 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 copayment forthe duplex scan provided on July 21, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance service (A0429) provided on July 16, 2020.You asked the Plan to waive the copayment forambulance service. You say that the service should be covered.The Plan denied your request. The Plan says the copayment was 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 $200 copayment for each one-way Medicare covered ground trip for ambulance services. You have been asked to pay a $200 copayment for each one-way Medicare covered ground trip for ambulance service. This service falls within the ambulance 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 forambulance service (A0429) provided on July 16, 2020
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are available in-network.Medicare rules say that plans can requireenrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe electrocardiogram (EKG) report and interpretation rendered on August 27, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 93010 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 93010 and 92928. Code 93010 is a column II code with a modifier indicator of 1 when billed with columnI code 92928. Code 93010 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe electrocardiogram (EKG) report and interpretation rendered on August 27, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 24, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services are available in-network.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 forthe medical services provided to the enrollee by an out-of-network provider on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided
on December 6, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree
with the charges because a program normally pays for the injections 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 Medicare Part B prescription drugs.
You have been asked to pay $194.88, which is less than 20% coinsurance for a Medicare Part B drug injection.
A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug injection provided on December 6,
2019.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to waive the deductible for physical therapy provided by a participating provider 
on September 2, 2020, to September 18, 2020. 
 
You asked the Plan to waive the deductible for physical therapy. You say that you should not be billed for this. 
The Plan denied your request. The Plan says that the correct deductible amount has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $0 copayment for outpatient rehabilitation services.  
 
The Plan says you must pay a $166.53 deductible for physical therapy. Based on the Plan contract, however, 
you cannot be asked to pay more than a $0 copayment for physical therapy. Therefore, we decided that the Plan 
has to waive the deductible for physical therapy provided by a participating provider on September 2, 2020, to 
September 18, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for new patient outpatient office visit (99205) outpatient office 
visit (99214, 99215) provided on July 20, 2020 to August 10, 2020 by an out of network (OON) provider.  
 
You asked the Plan to pay for the office visits. You say that you are a provider excluded from Medicaid by not 
Medicare. Therefore all claims for the medical services that you have provided to Medicare members should be 
promptly and fully paid. The Plan denied your request. The Plan says non-qualified Medicare provider. The 
provider is excluded or debarred from participation in State and Federal health care programs. 
 
The plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical 
care as long as the care you receive is considered medically necessary and you receive your care from a 
provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can 
receive your care from either a network provider or an out-of-network provider. 
 
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 new patient outpatient office visit (99205) 
outpatient office visit (99214, 99215) provided on July 20, 2020 to August 10, 2020 by an out of network 
(OON) provider.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Daratumumab (C9399). 
 
You asked the Plan to pre-approve Daratumumab. You say that the services are necessary. The Plan denied 
your request. The Plan says that based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Daratumumab. Our reviewer says that 
the medication is medically necessary Our physician reviewer found due to the rarity only case reports exist 
guiding treatment decision making. Responses have been reported after administration of therapies used for 
plasma cell dyscrasias (such as daratumumab) suggesting that these symptoms are at least partially related to 
the underlying plasma cell dyscrasia. The service is reasonable and 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 Daratumumab have been met. Therefore, we decided that the Plan has to pre-
approve Daratumumab (C9399).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prevacid. 
 
You asked the Plan to pre-approve Prevacid. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prevacid.  
 
Benefits for Prevacid 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on September 28, 2020. 
 
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
physical therapy 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 physical therapy services provided on September 
28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two surgical extractions, bone replacement graft for ridge 
preservation, biologic materials to aid in soft and osseous tissue regeneration, first 15 minutes of intravenous 
moderate (conscious) sedation/analgesia, and four subsequent 15 minute increments of intravenous moderate 
(conscious) sedation/analgesia provided on October 1, 2020. 
 
You asked the Plan to pay for the extractions, bone replacement graft, biologic materials, and intravenous 
moderate (conscious) sedation/analgesia. You say that prior to the services being rendered you were advised 
that this provider was not participating with your plan. The Plan denied your request. The Plan says these 
services 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, 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 two 
surgical extractions, bone replacement graft for ridge preservation, biologic materials to aid in soft and osseous 
tissue regeneration, first 15 minutes of intravenous moderate (conscious) sedation/analgesia, and four 
subsequent 15 minute increments of intravenous moderate (conscious) sedation/analgesia provided on October 
1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labial veneer (D2962) provided on September 15, 2020. 
 
You asked the Plan to pay for the labial veneer. You say that you feel that this service should be covered under 
your benefits. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 labial 
veneer (D2962) provided on September 15, 2020.