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

We decided that the Plan does not have to waive the coinsurance for the knee injection provided on March 12, 2021.
You asked the Plan to waive the coinsurance for Synvisc-One (J7325). You say that you have had this injection before and did not receive a bill. The Plan denied your request. The Plan says you were charged this coinsurance 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 Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the Synvisc-One injection (J7325). Synvisc-One (J7325) 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 the knee injection provided on March 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided March 10, 2021.
You asked the Plan to pay for the ambulance response. You say that you should not have to pay for the service since there was no transport. The Plan denied your request. The Plan says this service is not covered because there was no transport.
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 March 10, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
The trip report in this case shows that you were feeling better and refused transport to the hospital and thus the
wavier criteria is not met. Therefore, we decided that the Plan does not have to pay for the ambulance response
and treatment, no transport (A0998) provided March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on April 8, 2020, by an OON provider.
You asked the Plan to pay for office visit. You say that you were not aware that authorization was required. 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 authorization was 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 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 an office visit provided on April 8, 2020, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

You asked the Plan to pre-approve Synvisc-One. You say that this drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Synvisc-One. Our reviewer says that this drug is not medically necessary and reasonable. Our physician reviewer found this appeal considers the request for Synvisc-One for the treatment of primary osteoarthritis of the right knee. The enrollee has not trialed viscosupplemental treatment such as Orthovisc. Step therapy, as outlined by the plan, requires that this be trialed first. The documentation does not outline contraindications or reasons that this medication was not considered. Without the support of the documentation, Synvisc-One is not approved, as step criteria has not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a power wheelchair replacement. You asked the Plan to pay for the power wheelchair replacement. You say that you require a different power wheelchair. The Plan denied your request. The Plan says the coverage criteria for a replacement have not been met. The enrollee has previously received approval for a power wheelchair within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the enrollee was approved for the same durable medical equipment on June 7, 2021. This approval is still within the 5-year RUL and the documentation submitted does not show that the power wheelchair is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the alternate power wheelchair at issue. Based on this information, we decided that Medicare rules for coverage of the power wheelchair replacement have not been met. Therefore, we decided that the Plan does not have to pay for a power wheelchair replacement.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on March 2, 2021.

You asked the Plan to waive the copayment for emergency room visit. You say that you were sent to the emergency room because the doctor interpreted your imaging wrong. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $100 copayment for emergency room visit. 

You have been asked to pay $100 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided on March 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Butrans Dis 20mcg/Hr.
You asked the Plan to pre-approve Butrans Dis 20mcg/Hr. 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 Butrans Dis 20mcg/Hr.
Benefits for Butrans Dis 20mcg/Hr 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this case. Our physician reviewer found the procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inbrija.
You asked the Plan to pre-approve Inbrija. 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 selfadministered
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 Inbrija.
Benefits for Inbrija 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 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 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 have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided April 1, 2021.
You asked the Plan to pay for the radiology services. You say that the service should be covered. The Plan denied your request. The Plan says the deductible was not met at the time the services were rendered.
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 there is a $750 deductible for covered services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for covered services. This cost sharing is a contractual obligation that had not been met at the time the radiology services was received on April 1, 2021. Therefore, we decided that the Plan does not have to pay for radiology services provided April 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit rendered on March 31, 2021.
You asked the Plan to waive the deductible for these services. You say that you would like the claim paid as in-network. The Plan denied your request. The Plan says the deductible was applied correctly.
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 there is $500 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the out-of-network PCP and specialist services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on March 31, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit rendered on March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the $40 copayment charged for outpatient services provided on March 9, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the services rendered and your Plan contract agreement.
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 a $40 copayment for outpatient hospital laboratory services. 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 $40 copayment charged for outpatient services provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist services rendered on April 15, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. 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 $30 copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, and urgently needed services).
Review of the file shows that you received specialist services on April 15, 2021. You have been asked to pay a $30 copayment for these services. These services fall within the Medicare-covered specialist visit (including surgery second opinion, telehealth services, and urgently needed services) benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the specialist services rendered on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided December 11, 2020.
You asked the Plan to pay for the ambulance services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the CPT code billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT code A0429 is not supported in the medical record. Specifically, the record shows the enrollee was pronounced dead after the ambulance was called. In this case, the provider must bill code A0428 with the QL Modifier. 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 for ambulance services (A0429) provided December 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on November 19, 2020.
You asked the Plan to pay for the ambulance service. You say that the fire department responded to your call first. You say that they needed additional equipment, so another ambulance service was called. You also say that the fire department was the one to provide the transportation to the hospital. The Plan denied your request. The Plan says ambulance transportation is only covered when you are actually transported by ambulance. The Plan also says that because you were not transported by this ambulance, the service is not covered. in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished under a contract with a qualified basic life support (BLS), the provision of medically necessary supplies and services, with a volunteer ambulance company. In addition, State law must not allow the volunteer ambulance company to bill for the transport or BLS services. The Plan has confirmed that the ALS ambulance company does not have a contract with the volunteer ambulance company that provided the transport services. Therefore, we decided that the Plan does not have to pay for the paramedic intercept (A0432) provided on November 19, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing rendered on March 8, 2021.
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 billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing rendered on March 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility admission.
You asked the Plan to pre-approve a skilled nursing facility admission. You say that the enrollee needs SNF care. The Plan denied your request. The Plan says it does not appear the enrollee is in need of therapy at the level of intensity that requires a SNF at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 a skilled nursing facility admission. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation
does not reveal evidence of complex wound care or other skilled nursing treatment that requires a SNF
admission. The patient's functional level does not require skilled therapy services with the specialized skill,
knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and
reasonable treatment in a SNF. The patient does not require skilled nursing or skilled therapy services (or a
combination of these services) on a "daily basis" in a SNF. As a practical matter this patient does not require
the necessary services on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a skilled nursing facility admission have not been met. Therefore, we decided
that the Plan does not have to pre-approve a skilled nursing facility admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $460.20 applied to the deductible for medical services provided on November 23, 2020.
You asked the Plan to waive this cost share. You say that you do not believe this bill is correct. You say that the provider told you this claim was billed in error. The Plan denied your request. The Plan says the deductible was not satisfied at the time of service.
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 there is $500 deductible for 2020. The deductible was not satisfied on the day of service. This charge was generated based on the claim submitted by the provider. Therefore, we decided that the Plan does not have to waive the $460.20 applied to the deductible for medical services provided on November 23, 2020.