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

We decided that the Plan does not have to pay for the digital tomosynthesis.

You asked the Plan to pay for diagnostic digital breast tomosynthesis; bilateral (77062). You say that the Plan should pay this claim. The Plan denied your request. The Plan says Medicare rule for payment of this claim has not been met.

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 code 77062 has a status code of I and is not valid for Medicare purposes.

We find that CPT code 77062 is not a payable code. Based on this information, we decided that Medicare rules for coverage of diagnostic digital breast tomosynthesis; bilateral (77062) have not been met. Therefore, we decided that the Plan does not have to pay for the digital tomosynthesis.
Appeal type: Step-Therapy
Decision: Favorable

We decided that the Plan has to pre-approve use of denosumab (Prolia).

You asked the Plan to pre-approve denosumab. You say that you are appealing the denial of Prolia. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of oral/injectable bisphosphonates, estrogens, or calcitonin before it will approve denosumab.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract does not clearly indicate whether the Plan has implemented step therapy criteria applicable to denosumab. 

We looked at your contract with the Plan. We did not see where the contract says that step therapy rules have been implemented for use of denosumab. The Plan did not provide any other rationale to support a denial for the requested denosumab. Therefore, we decided that the Plan has to pre-approve use of denosumab (Prolia).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Botox injection (J0585) received September 16, 2020.

You asked the Plan to waive the coinsurance for the Botox injection. You say that you should not be charged coinsurance for the injection. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. 

You have been asked to pay a total of $243.80 ($1,219.00 allowed amount x 20% coinsurance = $243.80) for the Botox injection. This 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 the Botox injection (J0585) received September 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.

You asked the Plan to pre-approve a grab bar. You say that you need this to hold yourself so you do not fall in the bathroom. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because a grab bar is not covered by Medicare.

The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. 

While a grab bar 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 pre-approve a grab bar.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99213) provided November 4, 2020.

You asked the Plan to waive the copayment for the office visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.

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 $45 copayment for Specialist Visits. 

You have been asked to pay a $45 copayment for the office visit. The office visit falls within the Specialist Visits 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 office visit (99213) provided November 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for laboratory testing. You say that you are appealing the denial. The Plan denied your request. The Plan says the denial of payment for these services 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 the medical services provided on October 12, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair and elevating wheelchair leg rests provided on September 19, 2020.

You asked the Plan to pay for the standard wheelchair and elevating leg rests. You say that these services should be covered because this date of service is after the enrollee was released from hospice. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on September 12, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the standard wheelchair and elevating wheelchair leg rests provided on September 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met in the current setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short-term acute care hospitals. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share liability for the cataract surgery (66984) provided on August 20, 2020 and August 27, 2020.

You asked the Plan to waive the cost share liability. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share liability has been applied correctly to the services provided.

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 $100 copayment for surgery services at an outpatient hospital. Additionally, Medicare rules say that if an enrollee receives an anterior chamber intraocular lens during cataract surgery, the enrollee will be responsible for the difference in the cost between that lens and a conventional lens. 

You have been asked to pay $2,096.80 (Plan allowed amount of $5,988.82-$3,892.02 Paid) for the cataract surgery with toric lenses provided. Included in this amount is a $100 copayment applied for each surgery. Additionally, the record shows that you had cataract surgery and a special lens was requested to correct an astigmatism. Medicare rules say that if an enrollee receives an anterior chamber intraocular lens during cataract surgery, the enrollee will be responsible for the difference in the cost between that lens and a conventional lens. The astigmatism-correcting feature of an intraocular lens is not covered by Medicare. 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 cost share liability for the cataract surgery (66984) provided on August 20, 2020 and August 27, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care received on August 19 to September 2, 2020.

You asked the Plan to pay for SNF care. You say that the provided services are coverable under the Medicare Act. The Plan denied your request. The Plan says there were no daily skilled services provided on the dates of service at issue.

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 of this letter 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 that there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. The enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care received on August 19 to September 2, 2020.
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 IRF care is medically necessary. The Plan denied
your request. The Plan says IRF care is not medically necessary.

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 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. In addition, you do not
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. The medical record documents a need for physical and occupational
therapy but not for an intensive rehabilitation program. Medial necessary services could be provided in a low
level of care. Finally, there is a not reasonable expectation that you 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 air transport (A0430).

You asked the Plan to pay for the air transport. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not met.

The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.

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 air transport. Our reviewer says that the air ambulance service was not medically necessary. Our physician reviewer found the documentation did not support that the patient suffered from an illness or injury that contraindicated transportation by any means other than ambulance. Ground transportation was not contraindicated.

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 air transport have not been met. Therefore, we decided that the Plan does not have to pay for air transport (A0430).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay.

You asked the Plan to waive the copayment for inpatient stay. You say that you were not aware of such a copayment, and the Plan should cover this bill except the $275 you paid before your surgery. 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 $275 copayment per day for days 1 to 5 for inpatient hospital care. This inpatient stay lasted 6 days, resulting in a copayment obligation of $1,375.

You have been asked to pay $275 copayment per day for days 1 to 5 for inpatient stay. Inpatient stay falls within the Inpatient Hospital 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 inpatient hospital stay.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (36415, 84153).

You asked the Plan to waive the copayment for the lab services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment has been applied.

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 lab services.

You have been asked to pay a $20.00 copayment for the lab services. 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 lab services (36415, 84153).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided August 13, 2020.

You asked the Plan to pay for the hospital services. You say that the services were medically necessary. The Plan denied your request. The Plan says billing rules have not been met.

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 the outpatient hospital services are not supported in the record. Specifically, Indian Health Services claims are required to be billed with Type of Bill 13X and revenue code 0510, per the Medicare Claims Processing Manual, Chapter 19, Section 100.5.1. The claim submitted did not meet these requirements. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services provided August 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring physician 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 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 the medical services provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the lipid panel.

You asked the Plan to waive the deductible for the lab services. You say that the lab was part of your annual wellness exam. The Plan denied your request. The Plan says labs are not included in your annual wellness exam.

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 $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests and therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible for outpatient diagnostic tests and therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time the lab services was received on September 17, 2020. In addition, the Plan has clearly stated that the annual wellness visit does not include lab tests and immunizations. Therefore, we decided that the Plan does not have to waive the deductible for the lipid panel.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80061, 84443, 85025).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.

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 service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for lab services (80061, 84443, 85025).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an automated external defibrillator (AED) garment (LifeVest).

You asked the Plan to waive the coinsurance for LifeVest. You say that the provider told you this would not cost anything. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for LifeVest, up to a maximum out-of-pocket amount of $3,700. At the time this claim was processed, $3,276.33 of the $3,700 maximum out-of-pocket amount had been met. The allowed amount of the claim is $2,194.20, resulting in a coinsurance amount of $423.67 because this amount met the $3,700 maximum out-of-pocket amount.

You have been asked to pay 20% coinsurance for LifeVest. LifeVest falls within the Durable Medical Equipment (DME) 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 for an automated external defibrillator (AED) garment (LifeVest).