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

We decided that the Plan does not have to pay forthe subsequent hospital care provided on November 18, 2019 by an OON provider.You asked the Plan to pay forthe subsequent hospital care. You say that this claim needs to be reprocessed for payment with the authorization number that you have on file.The Plan denied your request. The Plan says the enrollee does not have out-of-network coverage without prior authorization.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 exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe subsequent hospital care provided on November 18, 2019 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's servicesfor an ophthalmic biometry calculation provided on August 19, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.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 servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decidedthat the Plan does not have to pay for physician's services for an ophthalmic biometry calculation provided on August 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on October 26, 2019.You asked the Plan to pay forthe ambulance services. You say that you were advised the transport would not guarantee immediate care at the hospital so you decided to wait.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on October 26, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on October 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI provided on October 25, 2019.You asked the Plan to waive the copayment forthe MRI. You say that you should not be responsible for the charge.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 $200 copayment for covered diagnostic radiology services in a provider's office or freestanding radiology center.You have been asked to pay a $200 copayment for the MRI. The MRI 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 enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe MRI provided on October 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forfluoroscopic guidance for needle placement services (CPT 77002) provided to the enrollee on September 6, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysCPT 77002 is an add-on code without the appropriate primary procedure.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 77002 is "Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in additional 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the enrollee received an epidural injection with fluoroscopic guidance. The base code (CPT 64484) already includes the fluoroscopic guidance. Billing forthe fluoroscopic guidance separately is not necessary or allowed. The billing of add-on code CPT 77002 is not supported.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 services have not been met.Therefore, we decided that the Plandoes not haveto pay forfluoroscopic guidance for needle placement services (CPT 77002) provided to the enrollee on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cochlear implant and accessories provided on October 17, 2019.You asked the Plan to pay forthe cochlear implant and accessories. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not provide the physician order.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order for the items at issue in this appeal. The record does not contain a valid physician order for the supplies provided in this case.Therefore, we decided that the Plan does not have to pay forthe cochlear implant and accessories provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided to the enrollee from July 17, 2019, to October 21, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says these services were paid on another claim.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a claim that is considered to be a duplicate for services that have been previously paid by the plan. 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 forthe services provided to the enrollee from July 17, 2019, to October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe prolonged evaluation and management service (99356) provided on October 26, 2019.You asked the Plan to pay for the prolonged evaluation and management service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support billing CPT code 99356 in addition to CPT code 99223.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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition tocode for inpatient Evaluation and Management service). We find that CPT code 99356 is not supported in the record. Specifically, the record does not indicate that an additional 30 to 74 minutes of time were spent rendering this evaluation and management service. Based on this information, we decided that Medicare rules for coverage of the prolonged evaluation and management service have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged evaluation and management service (99356) provided on October 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says treatment with other medicine must have not worked before approving Gel-One.
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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the alternative drugs. The records do not indicate that these drugs would be less effective or have adverse effects.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the cystourethroscopy provided on September 10, 2019.
You asked the Plan to waive the coinsurance for the cystourethroscopy. You say that you were told that the procedure was covered. The Plan denied 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 surgery performed at an in-network outpatient hospital facility. You have been asked to pay $1,497.82 which is 20% of the allowed amount for the cystourethroscopy. The allowed amount is $7,489.12. ($7,489.12 x 20% = $1,497.82). The cystourethroscopy 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 for the cystourethroscopy provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 21, 2019 by a non-participating provider.
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 rendered by a non-participating provider without prior authorization.
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 for the medical services provided on August 21, 2019 by a non-participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveRenflexis (Q5104) at 5mg/kg for induction and 5mg/kg at 2 and 6 weeks for the enrollee.You asked the Planto pre-approvethe dosage. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested dose is not indicated by the accepted standards of medical practice for this condition.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 the dosage. Our reviewer says that the requested dosing is not medically reasonable or necessary. Our physician reviewer found in the case of this enrollee, Renflexis at 5mg/kg for induction and 5mg/kg at 2 and 6 weeks was requested to be used to help treat diagnosed rheumatoid arthritis. The DrugDex was referenced which shows that current evidence supports using Renflexis for rheumatoid arthritis, however, with only up to 3mg/kg forinduction and maintenance therapy. The provided documentation and statements did not clearly describe how this case would require a higher dose than evidence supports. Therefore, without sufficient justification made for this request, the Renflexis 5 mg/kg dosing will be considered not medically necessary as submitted.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 dosage have not been met.Therefore, we decided that the Plandoes not haveto pre-approveRenflexis (Q5104) at 5mg/kg for induction and 5mg/kg at 2 and 6 weeks for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are skilled needs, but they do not need to be provided on a daily basis. The member's care can be appropriately provided through home-based and outpatient services with intermittent skilled services on a less than daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a facility-based full night titration study (CPT 95811)
for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your
request. The Plan says the records do not show a request for a in-home auto-titrating PAP study in the last six
months.
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 pre-approve the study. Our reviewer says that the
requested study is not considered medically reasonable and necessary in this case. Our physician reviewer
found coverage criteria for an attended, in-lab PAP titration are not met. This enrollee was reportedly doing
well on auto-titrating CPAP (APAP) until she had to discontinue it because of a facial injury. A formal PAP
titration is not medically necessary for this enrollee. She should be restarted on APAP. A titration would be
necessary only if APAP was not successful in resolving the sleep disordered breathing.
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 study have not been met. Therefore, we decided that the Plan does not have
to pre-approve a facility-based full night titration study (CPT 95811) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care provided on May 9, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for wound care. You say that these services were provided in a nursing home. You
say that these services were medically necessary. The Plan denied your request. The Plan says no prior
authorization was 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 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 for wound care provided on May 9, 2019 by an out of
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to reduce the cost forwound care supplies. We decided that the Plan does not have to waive the cost forwound care supplies. You asked the Plan to waive the cost forwound care supplies. You say that you did not order the medical supplies and did not use them. You say that you would send it back.The Plan says that the coinsurance applied correctly.We decided that the Planhas to reducethe cost forwound care supplies. 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 $40 copayment for in-network surgical supplies, such as dressings. The wound care supplies are considered medical supplies. Therefore, we decided that the Plan has to reduce the cost forwound care supplies. 
We also decided that the Plandoes not have to waive thecost forwound care supplies.Your contract with the Plan clearly says that you must pay a $40 copayment for in-network surgical supplies, such as dressings.Therefore, we decided that the Plan does not have to waive the cost forwound care supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 8, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was a wellness visit and you should not be charged a $10 copayment. The Plan denied 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 a $10 copayment for an in-network PCP office visit. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows other issues such as hypertension, gout, and chronic pain were addressed in addition to the wellness visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on November 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forpractitioner visit. You say that the facility requested this provider; therefore, medical necessity is pre-established.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with 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 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 decidedthat the Plan does not have to pay forthe medical services provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings and resin-based composite provided on November 1, 2019.
You asked the Plan to pay for the bitewings and resin-based composite. You say that you had a partial made and two months later it broke. The Plan denied your request. The Plan says the benefits for these services have been satisfied and the frequency limitations have been exceeded.
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, bitewings are limited to one set per calendar year and restorations are limited to one procedure per calendar year. The record shows that you received bitewing x-rays on September 25, 2019 and you received a filling on September 26, 2019 and your bitewings and restorations benefits were then exhausted. Therefore, we decided that the Plan does not have to pay for the bitewings and resin-based composite provided on November 1, 2019.
Your complaint about your issues with the provider 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.