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

We decided that the Plan does not have to waive the copayment for the office visit provided on October 28, 2019.You asked the Plan to waive the copayment forthe office visit. You say that this was an annual wellness visit. You say that you were informed not to pay because there was no charge.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 $10 copayment for in-network primary care physician office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls withinthe "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that amnesia, diabetes and hypertension were discussed during the office visit. 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 October 28, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of SNF services.You asked the Plan to pre-approvethe SNF services. You say that the servicesare medically necessary because the member has daily wound care needs.The Plan denied your request. The Plan says there is no clear benefit of inpatient skilled nursing as opposed to an alternative setting for care.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 member does not meet severity of illness or intensity of service criteria for an inpatientbasis in an SNF 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-approvethe continuation of SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe intraoperative neuromonitoring (IONM) provided inside the operating room billed with code 95940, the IONM provided outside of the operating room billed with code G0453, and the neuromuscular junction testing billed with code 95937 for services provided on August 20, 2019.You asked the Plan to pay forthe billed services. You say that both 95940 and G0453 can be paid as in this case, the technician was in the operating room, satisfying the definition of 95940, and the doctor was monitoring more than one case from outside of the operating room allowing for payment of G0453. 95937 is also supported since neuromuscular junction testing was necessary and performed.The Plan denied your request. The Plan says the records do not support the services being billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95940 is Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes. We find that the personal attendance in the operating room of a technician does not meet the requirements for payment under this code on the Physician Fee Schedule, as services of a technician are not considered physician services. The CPT code definition of G0453 is Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes. We find that this code is not supported as there is no evidence that the neurologist billing this code was exclusively monitoring one single patient. The documentation suggests this physician was monitoring multiple patients from outside the operating room which does not meet the definition ofthis code. CPT code 95937 is defined as Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. This code is being used to represent Train of Four testing which is not separately payable as it is intrinsic to IONM.Based on this information, we find that the Medicare rules for coverage of these billed services have not been met.Therefore, we decided that the Plan does not have to pay forthe intraoperative neuromonitoring (IONM) provided inside the operating room billed with code 95940, the IONM provided outside of the operating room billed with code G0453, and the neuromuscular junction testing billed with code 95937 for services provided on August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve meal delivery service.You asked the Plan to pre-approve meal delivery service. You say that you don't cook, and are alone the majority of the day.The Plan denied your request. The Plan says home delivered meals are not covered under any condition.The Plan must follow Medicare rules. Medicare rules say that services for which the sole purpose is to enable the patient to continue residing in their homeare excluded from health coverage. We looked at the file and Medicare rules. Meals on Wheels is not a benefit under Medicare or your plan. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approve meal delivery service
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that the admission is medically necessary because the member needs to improve mobility and needs assistance walking. The Plan denied your request. The Plan says the member does not meet needs for daily skilled therapy services.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in an SNF 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a mammogram provided on October 22, 2019.You asked the Plan to pay for the mammogram. You say that when you went to the office, you gave them your insurance card and you were told this service would be covered. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 did not pre-approve the mammogram.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 a mammogram provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 47562) provided to the enrollee on July 15, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.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 47562 is "Laparoscopy, surgical; cholecystectomy".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 services. Our reviewer says that the use of CPT code 47562 is not supported by the records provided. Our physician reviewer found that the immediate post-operative note indicates that thesurgery occurred on July 14, 2019, at 2227. The operative note, dictated on July 17, 2019, indicates that the surgery occurred on July 14, 2019, at 2227. While the surgery may have extended into 7/15/2019, the billed DOS for the surgery should be the dateon which the surgery was initiated. Therefore, the billing of CPT 47562 on July 15, 2019, is not supported.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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 47562) provided to the enrollee on July 15, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Xalatan 0.005% solution.You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denial as the member has tried and failed multiple medications.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Xalatan 0.005% solution.Benefits for this medicationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerningany benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CYP panel rendered  on September 17,
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 testing is not covered.
The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are
non-covered.
The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code.
Furthermore, this testing is not covered by Medicare.. Therefore, we decided that the Plan does not have to pay
for the CYP panel rendered on September 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 24, 2019.
You asked the Plan to waive the copayment for the office visit. You say that your copayment should be $40. 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 $45 copayment for Medicare-covered podiatry visits. You have been asked to pay a $45 copayment for the office visit. The office visit falls within the "Podiatry services" benefit category. The records show that the provider is a podiatrist. 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 office visit provided on October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided from July 3, 2019 to July 5, 2019.You asked the Plan to pay forthese drugs. You say that you did not self-administer any drugs.The Plan denied your request. The Plan says self-administered drugs are not covered under Part B.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 pay forthe self-administered drugs provided from July 3, 2019 to July 5, 2019.Benefits for these drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Keytruda infusions and related laboratory services provided from November 1, 2018 to November 28, 2018.You asked the Plan to pay for the Keytruda infusions and related laboratory services. You say that the enrollee presented with traditional Medicare as his primary insurance and you found out that the enrollee had a Medicare Advantage Plan after the services were provided on December 13, 2018. The Plan denied your request. The Plan says the services were non-emergent and not authorized by 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 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 Keytruda infusions and related laboratory services provided from November 1, 2018 to November 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212), mechanical traction therapy (97012), electrical stimulation therapy (G0283), and the extra-spinal chiropractic manipulative treatment (98943) provided July 3, 2019 to July 9, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial as the services provided were medically necessary. The Plan denied your request. The Plan says the
services are not a covered benefit by Medicare or the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the office visit (99212), mechanical traction therapy (97012), electrical
stimulation therapy (G0283), and the extra-spinal chiropractic manipulative treatment (98943) provided July 3, 2019 to July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on August 1,
2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical
records (signed and dated by the ordering physician); therefore the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be
covered.
The documentation submitted did not include a physician order/lab requisition or medical records stating
exactly tests were 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 drug testing
services provided to the enrollee on August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen concentrator purchased on April 23, 2019.You asked the Plan to pay forthe portable oxygen concentrator. You say that you are requesting reimbursement of services rendered.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Your medical record shows that you need and have oxygen for home and bought this concentrator to improve your ability to get around. You purchased an oxygen concentrator. The rules say that only rentedoxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered.Therefore, we decided that the Plan does not have to pay forportable oxygen concentrator purchased on April 23, 2019
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a periprosthetic capsulectomy of the breast.You asked the Plan to pre-approve the removal of implants and capsulectomies. You say that it is medically necessary for the implants to be removed. The Plan denied your request. The Plan says that this procedure is considered cosmetic and therefore not reasonable or necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the removal of implants and capsulectomies. Our reviewer says that the documentation provided in the medical records support that there could be interference with a diagnosis of breast cancer (or other cancers), due to the presence of the implants. Our physician reviewer found you have moderate to severe pain of the breasts that may improve or resolve with the requested proceduresWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the removal of implants and capsulectomies have been met. Therefore, we decided that the Plan has to pre-approve a periprosthetic capsulectomy of the breast.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 the special pump services rendered to enrollee on September 12, 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 procedure code 99190 is not covered.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered to enrollee on September 12, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.You asked the Plan to pre-approvethese services. You say that other medications haven't helped.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 a diagnosis of spasmodic torticollis. The records do not show that he has tried and failed the plan's required drug, Dysport. The records do not support that Dysport would be less effective orcontraindicated; therefore, the requested Botox is not reasonable or medically necessary at this time.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-approveBotox.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on January 17, 2019.You asked the Plan to pay for train of four testing. You say that this was medically necessary.The Plan denied your request. The Plan says payment of this service is bundled into other services.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 95999 is not supported in themedical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing (95999) provided on January 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 6, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
that 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 subsequent nursing facility care provided on August 6, 2019.