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

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided by a participating facility on January 27, 2020.You asked the Plan to waive the copayment for outpatient hospital services. You say that you did not choose the location of this procedure. You say that you should not be charged this much. 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 $350 copayment for outpatient surgery/outpatient hospital facility. You have been asked to pay a $350 copayment for outpatient hospital services. Outpatient hospital services fall within the outpatient surgery/outpatient hospital facility 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 outpatient hospital services provided by a participating facility on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 2, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a signed physician's order for the specific tests billed; therefore the billed code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing services provided on April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic testing supplies for a Continuous Glucose
Monitor (CGM) (A9276, 99999).
You asked the Plan to pre-approve the continuous glucose monitor suppplies. You say that the items are
medically necessary. The Plan denied your request. The Plan says the CGM billed does not meet Medicare
rules for coverage as a Therapeutic CGM. Supplies for non-therapeutic CGM's are not covered.
The Plan must follow Medicare rules. Medicare rules say that only therapeutic CGM's are covered. Code
A9276 is used for supplies for non-therapeutic CGM's and is not covered.
We looked at the file and Medicare rules. The supplies requested are for a CGM that is not covered by
Medicare. Based on this information, we decided that Medicare rules for coverage of the continuous glucose
monitor suppplies have not been met. Therefore, we decided that the Plan does not have to pre-approve diabetic
testing supplies for a Continuous Glucose Monitor (CGM) (A9276, 99999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens, per lens (V2781) and vision item or service (V2799) purchased on January 2, 2020 from an out-of-network provider.
You asked the Plan to pay for the items. You say that the claim should have been processed differently. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Review of the file show that you purchased progressive lens, per lens (V2781) and vision item or service (V2799) on January 2, 2020. The plan covers one pair of glasses following cataract surgery, progressive lenses are not stated as a covered benefit. Furthermore, vision item or service (V2799) was billed incorrectly and there is no payment needed from you for this service. Therefore, we decided that the Plan does not have to pay for progressive lens, per lens (V2781) and vision item or service (V2799) purchased on January 2, 2020 from an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Montelukast Sodium.
You asked the Plan to pre-approve Montelukast Sodium. You say that the medication is medically necessary. The Plan denied your request. The Plan says coverage is not available under the Part B Medical benefit for this drug.
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 Montelukast Sodium.
Benefits for Montelukast Sodium 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 71045 provided on January 8, 2020.
You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the health plan sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The file does not contain documentation showing that CPT code 71045 was billed appropriately. Medical records were only provided from one provider. The medical records from the other providers would be necessary to determine if the claim at issue in this appeal is actually a duplicate claim. Therefore, we decided that the Plan does not have to pay for CPT code 71045 provided on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from December 6, 2019, to December 7, 2019.You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee could have been transferred to an in-network facility.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the documentation indicated that by 10:00 a.m. on December 6, 2019, the enrollee was stable for safe transfer to a Plan facility because her acute stroke was identified, and she was sent for emergent thrombectomy and revascularization; there were no complications. She was monitored and remained hemodynamically stable with no further decline in her neurological status. Post-stabilization care after 10:00 a.m. on December 6, 2019, was not medically necessaryor reasonable. The documentation indicated that the treating physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any dates of service.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 inpatient care have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient care provided from December 6, 2019, to December 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
SNF care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for a SNF
admission.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received enteral
medications and IV antibiotics. The enrollee had stable vital signs. The enrollee had routine Foley catheter and
tracheostomy care. The enrollee received physical therapy in the acute hospital and was dependent for
functional mobility. There are identifiable skilled nursing service needs, but they are not required on a daily
basis. There are no identifiable skilled therapy service needs. The enrollee does not meet the 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 the SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the OON services. You say that the enrollee needs to begin treatment. The
Plan denied your request. The Plan says you must receive your care from a network provider.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve
oncology services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lidocaine.
You asked the Plan to pre-approve Lidocaine. You say that Lidocaine is medically necessary. The Plan denied
your request. The Plan says Lidocaine is not covered under Medicare Part B.
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 Lidocaine.
Benefits for Lidocaine 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95937, 95885, and 95908 provided on January 23, 2019.
You asked the Plan to pay for CPT codes 95937, 95885, and 95908. You say that the medical records support the billing of CPT codes 95937, 95885, and 95908. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95937, 95885, and 95908.
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 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The CPT Code Manual definition of code 95908 is Nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT codes 95937, 95885, and 95908. Our reviewer says that the medical records do not support the billing of CPT codes 95937, 95885, and 95908. Our physician reviewer found based on the documentation provided, the enrollee received intraoperative monitoring. There is no evidence that the enrollee received diagnostic neuromuscular junction testing. Therefore, the billing of CPT 95937 is not supported. The enrollee received intraoperative monitoring. There is no evidence that the enrollee received diagnostic nerve conduction studies. Therefore, the billing of CPT 95908 is not supported. CPT 95885 must be billed in conjunction with nerve conduction studies. As nerve conduction studies were not performed, CPT 95885 cannot be billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT codes 95937, 95885, and 95908 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 95937, 95885, and 95908 provided on January 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET Scan with CT (78815).You asked the Plan to pre-approve the PET CT. You say that you would like reconsideration because the member is suspected of having an occult cancer which recently caused complications.The Plan denied your request. The Plan says the PET is not being used to guide cancer treatment.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET CT. Our reviewer says that the member does not meet NCD criteria for the PET CT. Our physician reviewer found the record does not indicate that there is a strongly suspected malignancy.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 PET CT have not been met.Therefore, we decided that the Plan does not have to pre-approve a PET Scan with CT (78815).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Synvisc-One.You asked the Plan to pre-approve Synvisc-One. You say that a cortisone injection has not worked.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc or Monovisc before it will approve Synvisc.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 the enrollee does not meet the Medicare criteria for a step therapy exception for Synvisc-One. Our physician reviewer found the documentation does not show that the enrollee has tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation does not support that Orthovisc or Monovisc would likely be less effective and/or have adverse effects for the enrollee.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 use of Synvisc-One.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from June 13, 2018
through July 1, 2018 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was reprocessed accordingly with your 2018 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received inpatient hospital care from June 13, 2018 through July 1, 2018 from
an in-network provider. You are asked to pay a $255 per day copay for days 1 through 7; $0 copay per day for
days 8 through 90; $0 per days 91-beyond. 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 inpatient
hospital care from June 13, 2018 through July 1, 2018 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.You asked the Plan to pre-approveCardio Mems. You say that this device is medically necessary.The Plan denied your request. The Plan says this device is experimental.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not cover experimental or investigational devices. 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 CardioMems. Our reviewer says that this device is still be considered experimental or investigational by Medicare. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CardioMems have not been met.Therefore, we decided that the Plan does not have to pre-approve a CardioMems device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services provided on February 7, 2020.
You asked the Plan to pay for the periodic comprehensive preventive medicine reevaluation and management services. 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 supported by the documentation.
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 99396 is periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years. We find that CPT code 99396 is not supported in the medical record. Specifically, this code was reported with a smoking and tobacco cessation counseling visit. This code is not billed for the rendering provider that it was billed with. Based on this information, we decided that Medicare rules for coverage of the periodic comprehensive preventive medicine reevaluation and management services have not been met. Therefore, we decided that the Plan does not have to pay for the periodic comprehensive preventive medicine reevaluation and management services provided on February 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from January 12, 2020 to January 15, 2020.
You asked the Plan to pay for inpatient hospital care. You say that the hospital tried to transfer the enrollee, but the social worker advised the enrollee that everything would be covered. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the hospital did not get approval for post-stabilization care and the enrollee's condition was safe to transfer to an in-network hospital.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient hospital care. Our reviewer says that these post-stabilization services do not meet the Medicare criteria for coverage. Our physician reviewer
found no records for the dates of service in question have been submitted for review. As such, there are no records to support that the care provided was medically reasonable and 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 inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from January 12, 2020 to January 15, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGelsyn-3.You asked the Plan to pre-approvethese 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 wascorrect 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 bilateral primary osteoarthritis of the knees. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not support that the drugs would be less effective or contraindicated; therefore, Gelsyn-3 is not 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-approveGelsyn-3.