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

We decided that the Plan does not have to pay for molecular pathology services provided on September 4, 2019.You asked the Plan to pay for the molecular pathology services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for molecular pathology services provided on September 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on August 22, 2019.You asked the Plan to pay for the unlisted neurological or neuromuscular diagnostic procedure. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not separately payable.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We find that CPT code 95999 is not supported in the medical record. Specifically, the documentation shows that the enrollee underwent back surgery requiring neurophysiology monitoring. Code 95999 is considered a bundled procedure as the cost is included in the cost of the primary procedure. Based on this information, we decided that Medicare rules for coverage of the unlisted neurological or neuromuscular diagnostic procedure have not been met.Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure coded 95999 provided on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on January 8, 2020 and January 13, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 services 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 chiropractic services provided on January 8, 2020 and January 13, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the coinsurance for the IV infusion. We decided that the Plan does not have to waive the coinsurance for the natalizumab injection and saline infusion.
You asked the Plan to waive the coinsurance for the IV infusion. You say that your previous infusions cost $95. You say that the claim should be reprocessed. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to waive the coinsurance for the IV infusion.
Your contract with the Plan clearly says that you pay a $0 copayment for provider and professional services at an in-network outpatient hospital. The IV infusion is considered a physician service. The Plan says that you must pay $31.95 for the IV infusion. Based on the Plan contract, however, you cannot be asked to pay more than $0. Therefore, we decided that the Plan has to waive the coinsurance for the IV infusion.
We also decided that the Plan does not have to waive the coinsurance for the natalizumab injection and saline infusion.
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 the natalizumab injection and saline infusion. Therefore, we decided that the Plan does not have to waive the coinsurance for the natalizumab injection and saline infusion.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 11, 2019.You asked the Plan to pay for the subsequent nursing facility care. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the foreign body removal procedure provided on October 22, 2019.
You asked the Plan to reduce the copayment for the foreign body removal procedure. You say that you went to the doctor for a skin condition and the provider ended up removing part of your hearing aid. You say you would like this to be your office visit 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 $400 copayment for Medicare-covered in-network outpatient hospital surgery services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $400 copayment for the foreign body removal procedure.
You have been asked to pay a $296.84 copayment for the foreign body removal procedure. The foreign body removal procedure falls within the hospital "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital for this procedure.
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 reduce the copayment for the foreign body removal procedure provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on an esophagogastroduodenoscopy (43235) provided on November 21, 2019.
You asked the Plan to pay for surgical assistant services. You say that this provider was requested by the in-network physician. The Plan denied your request. The Plan says surgical assistant services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 43235. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on an esophagogastroduodenoscopy (43235) provided on November 21, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy with maxillary antrostomy, nasal/sinus endoscopy, surgical with ethmoidectomy, and nasal/sinus endoscopy with frontal sinus exploration provided on December 7, 2019.You asked the Plan to pay for the nasal/sinus endoscopy services. You say that you were on hospice at the time of these services, but this diagnosis is unrelated to your hospice diagnosis.The Plan denied your request. The Plan says that Original Medicare is responsible for the hospice services that are related or unrelated to your hospice diagnosis.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy with maxillary antrostomy, nasal/sinus endoscopy, surgical with ethmoidectomy, and nasal/sinus endoscopy with frontal sinus exploration provided on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oscillation system provided on November 2, 2019 and December 2, 2019.
You asked the Plan to waive the coinsurance for the oscillation system. You say that you informed the provider you couldn't afford the price. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare-covered items. You have been asked to pay a total of $489.62 for the oscillation system.
The oscillation system 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 the oscillation system provided on November 2, 2019 and December 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. The Plan denied your request. The Plan says a semi-electric hospital bed is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that a semi-electric hospital bed is not medically reasonable and necessary in this case. Your condition does not require positioning of the body in ways not feasible in an ordinary bed. There is no evidence that you need frequent or immediate changes in body position or are unable to be propped up with wedges or pillows. There is no evidence that your medical condition needs a special attachment that cannot be fixed and used on an ordinary bed for your urostomy bag or other condition. Our physician reviewer found that your condition does not meet Medicare criteria for a semi-electric hospital bed.
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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not a covered benefit.
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 Ondansetron.
Benefits for these services 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: Favorable

We decided that the Plan has to waive the copayment for an office visit provided on January 26, 2020.
You asked the Plan to reduce the copayment for an office visit. You say that you should only owe a $20 copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
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. There were no records submitted to support whether the provider is a primary care physician or a specialist. Therefore, we decided that the Plan has to waive the copayment for an office visit provided on January 26, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has pain related to
osteoarthritis of the right knee, confirmed with imaging and failed conservative treatment. She has not tried and
failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the required drugs
would be less effective or contraindicated; therefore, the Genvisc is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Genvisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on October 24, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the record does not include the time spent providing critical care services, therefore this service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on November 18, 2019.You asked the Plan to pay for the subsequent nursing facility care. 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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on November 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased on March 14, 2018.
You asked the Plan to pay for the hearing aids. You say that you request reconsideration on the denial of this claim based upon misinformation provided by the plan representatives and the 2018 Evidence of Coverage. The Plan denied your request. The Plan says hearing aids must be purchased from the provider to be covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered directly from the provider. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids purchased on March 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient visit rendered on September 27, 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 99326 is not supported.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  is new patient assisted living visit, typically 45 minutes.We find that CPT code  is not supported in the medical record. Specifically, the file shows that the enrollee received services from a provider within the same group practice on September 24, 2019; therefore, a new patient visit does not apply. 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 new patient visit rendered on September 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.You asked the Plan to pre-approve additional routine transportation trips. You say that the enrollee needs transportation to receive radiation treatment.The Plan denied your request. The Plan says that the request exceeds the benefit limit.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of thirty (30) trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator for the enrollee.You asked the Plan to pre-approvea home ventilator. The Plan denied your request. The Plan says that records =show that Bi-PAP has been used in the hospital and did help the enrollee's condition.The Plan must follow Medicare rules. The rules say that ventilators may be covered when theyare medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have COPD. There is no evidence that the enrollee has a neuromuscular disease or restrictive thoracic disease. While the enrollee was previously on home oxygen, there is no evidence that the enrollee has tried home BiPAP/CPAP. The enrollee appears to have responded well to BiPAP in the hospital. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator.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 home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator for the enrollee.