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

We decided that the Plan does not have to pay for a screening prostate specific antigen (PSA) test provided on September 25, 2019.
You asked the Plan to pay for screening PSA test. You say that you were not told prior to service that the provider would be performing this test. The Plan denied your request. The Plan says the denial of payment for this service is correct, because screening PSA testing is covered once every 12 months and you had a prior screening PSA test performed on April 5, 2019.
The Plan must follow Medicare rules. Medicare rules say that screening PSA testing is covered once every 12 months for men who have attained the age of 50 years. We looked at the file and Medicare rules. You received a screening PSA test on April 5, 2019; therefore 12 months had not passed before this service was provided. Based on this information, we decided that Medicare rules for coverage of screening PSA test have not been met. Therefore, we decided that the Plan does not have to pay for a screening prostate specific antigen (PSA) test provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 7, 2019.You asked the Plan to pay forthe assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment of this service is included in the DRG payment.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay forthe assembly and operation of pump with oxygenator or heat exchanger (99190) provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One medication (J7325).
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary as the enrollee has bilateral primary osteoarthritis of the knees. The Plan denied your request. The Plan says the requested drug is subject to step therapy. This requirement encourages you to try the preferred drugs, which are just as effective: Monovisc and Orthovisc. Documentation was not received supporting the medical necessity for a step therapy exception.
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 this medication. Our reviewer says that the enrollee does not meet criteria for coverage of the Synvisc-One medication. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these drugs be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc-One is not approved as step therapy criteria is not 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 this medication have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One medication (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on August 14, 2019.You asked the Plan to pay forthe dental services. You say that your teeth were cleaned by the dental hygienist. You say that when the dentist came in to check the procedure, you mentioned a slight sensation. You also say that you did not receive a periodic oral evaluation.The Plan denied your request. The Plan says the frequency limit has 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 and periodic oral evaluations are a covered service, the frequency limit has been reached.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation (D0120) provided on August 14, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe magnetic resonance angiogram (MRA) of the head rendered to the enrollee on September 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 70544 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 70544 and 70551. Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe magnetic resonance angiogram(MRA) of the head rendered to the enrollee on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara Injections.
You asked the Plan to pre-approve Stelara Injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Stelara Injections are not covered under the enrollee's Medicare Part B benefit. The Plan says that they believe the enrollee's pharmacy benefit manager is Express Scripts.
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 Stelara Injections.
Benefits for Stelara Injections 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay formedical supplies (HCPCS L3960) provided to the enrollee on September 17, 2019.You asked the Plan to pay forthe supplies. You say that this is medically necessary.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the treating physician.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a coveredservice under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay formedical supplies (HCPCS L3960) provided to the enrollee on September 17, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay forambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient (CPT Code E0781) provided to the enrollee on April 14, 2018.You asked the Plan to pay forthe services. You say that the services are medically necessary and that is normal practice of the provider to obtain prior authorization per the plan guidelines. You state the services were provided without delay due to the condition of the patient and that you are a participating provider.The Plan denied your request. The Plan says that there was no authorization.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records provided are not sufficient to make a determination as we would need to see if the ordering physician was in-network with the Plan. No medical records were provided to verify if the services were emergent.Therefore, we decided that the Plan has to pay forambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient (CPT Code E0781) provided to the enrollee on April 14, 2018.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 waive the copayment for the office visit provided on April 19, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the phlebotomy is not an office call. You say that you do not see a doctor.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 $35 copayment for each in-network specialist visit for Medicare-covered benefits.You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that you had an office visit with a specialist on April 19, 2019. 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 office visit provided on April 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent observation care rendered to you on October 15, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plandenied your request. The Plan says the claim was not billed with the correct place of service (POS) code.The Plan must follow Medicare rules. Medicare rules say that POS code 21 is used for reporting inpatient services.We looked at the file and Medicare rules. The file shows that the provider submitted a claim for procedure code 99226 for subsequent hospital care with POS code 21 for inpatient hospital services. An inpatient POS code is not appropriate for the outpatient services.Therefore, we decided that the Plan does not have to pay forthe subsequent observation care rendered to you on October 15, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit or the laboratory test provided on September 4, 2019.
You asked the Plan to waive the cost share for the office visit and the laboratory test. You say that you feel you should not have to pay this. You say the wellness exam has no 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 a primary care physician and 10% coinsurance for laboratory tests. You have been asked to pay a total of $10.30 for the office visit and the laboratory test. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The laboratory test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows you were seen for an evaluation for your chronic medical problems. See chart below.
Date of Service
Service
Allowed Amount
Copayment/Coinsurance
Member Liability
September 4, 2019
Office visit
$105.66
$10.00
$10.00
September 4, 2019
Lab test
$3.00
10%
$0.30
Total
$10.30
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 for the office visit or the laboratory test provided on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on August 16, 2019.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 are not covered.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.The provider submitted a claim for procedure codes 88307-26 and 88346-26. The professional component for these services is not separately payable because the services were performed in a facility setting.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on August 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to the enrollee from June 4, 2019 to June 25, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered with code 85. We looked at the file and Medicare rules. The claim was not billed with the required FIPS code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered to the enrollee from June 4, 2019 to June 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on August 13, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you have never received a bill for laboratory work in the past. You say your doctor thinks the copayment was due to the blood work being sent to the hospital. 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 Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were billed by the hospital.
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 laboratory work provided on August 13, 2019.
Our decision is only about the August 13, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build up (D2950) provided on September 9, 2019.
You asked the Plan to pay for the dental service. You say that you cannot afford to pay the $350 bill that you received for the dental service. You also say that the dentist filled the back of your tooth only. The Plan denied your request. The Plan says core build up is not a covered service.
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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core build up (D2950) provided on September 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe digital breast tomosynthesis rendered to the enrolleeon August 29, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 77062 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.The provider submitted a claim for code 77062. This code has a status indicator of I and is not valid for Medicare purposes.Therefore, we decided that the Plan does not have to pay forthe digital breast tomosynthesis rendered to the enrollee on August 29, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount forthe surgical extraction (D7250) provided on July 15, 2019.You asked the Plan to reimburse the full amount forthe dental service. The Plan denied your request. The Plan says the cost sharing amount of $242.50 was applied correctly.Medicare generally does not cover dental services. However, the Plan offers a dental benefit thatexceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and surgical extractions are a covered service, you are responsible for the 50% coinsurance when it is received out of network. Additionally, there is a $100 deductible that must be satisfied. Cost sharing is a contractual obligation under the plan and cannot be waived.Therefore, we decided that the Plan does not have to reimburse the full amount forthe surgical extraction (D7250) provided on July 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean open magnetic resonance imaging (MRI) of the chest spine (72146) and an open MRI of the neck spine (72141) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean open MRI of the chest spine and an open MRI of the neck spine. You say that the service is necessary since the enrollee has severe claustrophobia.The Plan denied your request. The Plan says the enrollee has not tried and failed the Large Bore Lighted MRI that is available in-network. This would have to be attempted before consideration could be given to an open MRI out-of-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 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-approvean open magnetic resonance imaging (MRI) of the chest spine (72146) and an open MRI of the neck spine (72141) to be provided by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 1, 2019 to July 3, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the enrollee continued to make progress with the continued delivery of Speech, Occupational, and Physical therapy. You also say that under Medicare guidelines, continued progress is justification that the enrollee continued to meet the medical necessity guidelines for receiving skilled care.The Plan denied your request. The Plan says the enrollee did not meet the medical necessity for inpatient skilled rehabilitation at a SNF.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.
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-approveIRF 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 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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee's functional level and activity tolerance does not require this therapy on an intensive rehabilitation facility therapy program level 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-approveacute inpatient rehabilitation facility (IRF) admission and services.