Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are other services that may be available as part of the enrollee's mental health benefits.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided for this admission, the enrollee does not meet the criteria for continued inpatient mental health treatment for 6/29/20 onward. The enrollee was not shown to be a danger to herself or others. The enrollee was not showing any auditory or visual hallucinations, and was cooperative/compliant with with treatment, while not showing any threats to safety. 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 pre-approve inpatient mental health services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for PT/INR testing (G0249) provided on January 14, 2020 through January 20, 2020.
You asked the Plan to pay for the PT/INR testing. You say that this service was billed in accordance with Medicare guidelines. The Plan denied your request. The Plan says this service does not meet Medicare NCD criteria.
The Plan must follow Medicare rules. Medicare rules say that testing with the home PT/INR system should not be done more than once per week. In this case, the definition of the code G0249 is Provision of test materials and equipment for home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PT/INR testing have not been met. As this code encompasses four tests, billing for four tests weekly exceeds what is covered by Medicare. Evidence was submitted showing that payment for this code was made on January 3, 2020. Therefore, we decided that the Plan does not have to pay for PT/INR testing (G0249) provided on January 14, 2020 through January 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an Electrocardiogram (93042) provided October 10, 2019.
You asked the Plan to pay for the Electrocardiogram. You say that the services were medically necessary. The Plan denied your request. The Plan says payment for this service was included in payment for another code 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, we have confirmed that code 93042 has a bundled relationship with code 93010 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an Electrocardiogram (93042) provided October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

You asked the Plan to pay for the acute inpatient hospital care. You say that the acute inpatient hospital care provided was medically necessary for the enrollee. The Plan denied your request. The Plan says that the acute inpatient hospital care provided was not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the Emergency Department (ED) on September 16, 2018 with a report of missing hemodialysis for two weeks. He stated that he had been traveling for work and felt overloaded with edema in his legs and a temporal pressure like headache. He also reported nausea and vomiting and green colored diarrhea. The enrollee was admitted and underwent dialysis. His condition stabilized and improved with medical treatment and he was discharged when considered medically stable on September 22, 2018, with outpatient follow-up including regular hemodialysis. The review has determined that the record showed that at the time of the inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided September 16, 2018 to September 22, 2018.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 9, 2020.
You asked the Plan to pay for lab test. You say that you only perform this test in your hospital lab. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.
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 laboratory testing provided on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0428, A0425) provided January 3, 2020.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay a $200 copayment for ambulance services. The enrollee has been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance transport (A0428, A0425) provided January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance transport provided on March 3, 2020.
You asked the Plan to waive the deductible for the ambulance transport. You say that you have many bills coming through. You say that insurance could have paid a little more. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Ambulance services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for falls within the "Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to ambulance services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on March 3, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance transport provided on March 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 13, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says 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 February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition.
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 February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided February 12, 2020.
You asked the Plan to pay for the orthosis. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee received this same item on March 30, 2017 from a different provider. The records submitted did not include documentation to support that the replacement of this brace was necessary due to loss or irreparable damage.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the enrolle had L0650 at the time the orthosis was received. L0650 serves the same purpose as the orthosis. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650) provided February 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for educational supplies provided on April 15, 2019.
You asked the Plan to pay for the provided supplies. The Plan denied your request. The Plan says the code is included in the payment of other services performed on the same 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 99071 is educational supplies, such as books, tapes, and pamphlets, for the patient's education at cost to physician or other qualified health care professional. We find that CPT code 99071 is a bundled code. This code cannot be paid as a separate line item. 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 pay for educational supplies provided on April 15, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta.
You asked the Plan to pre-approve Zilretta. You say that this is necessary to avoid surgery until it is safe. The Plan denied your request. The Plan says that this drug is not recommended for repeat administration.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that the criteria for coverage of Zilretta have been met. Our physician reviewer found where the labeling once stated that Zilretta is not intended for repeat administration, the labeling now states that the safety and efficacy of repeat administration has not been established. There is now medical literature supporting the safety and efficacy of a second injection of extended-relief triamcinolone acetonide. A second injection of the drug resulted in a similar magnitude and duration of clinical benefit as a first injection, and was well-tolerated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zilretta have been met. Therefore, we decided that the Plan has to pre-approve Zilretta.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on January 18, 2020.
You asked the Plan to pay for the testing. You say that the lab performed all of the tests that were ordered by the referring physician. The Plan denied your request. The Plan says Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for the testing. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. The initial urinalysis was non-actionable. Therefore, there is no evidence to support that the molecular genetic urine test was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s). 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for molecular genetic screening testing provided to the enrollee on January 18, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided from November 18, 2019 to
February 27, 2020.
You asked the Plan to pay for the psychotherapy services. You say that your PCP recommended providers, but
those providers could not take you and they recommended other providers. You say that this provider was able
to treat you and you made the appointment for November 18, 2019 and continued to see this provider. You say
that neither the provider or the Plan told you that you would be financially responsible for these services. 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
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 psychotherapy services provided from November 18, 2019 to
February 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Osmolex (J8499).
You asked the Plan to pre-approve Osmolex. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Osmolex (J8499).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce to the coinsurance the ECG provided on November 18, 2019.
You asked the Plan to reduce to the coinsurance the ECG. You say that you were not aware the provider was
out-of-network. You say you would like the claim processed as in-network. 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 50% of
the Medicare-allowed amount for each out-of-network Medicare-covered diagnostic procedure and test in all
settings.
You have been asked to pay $8.31 which is 50% of the allowed amount for the ECG. The allowed amount is
$16.62. ($16.62 x 50% = $8.31). The ECG falls within the "Outpatient diagnostic tests and therapeutic services
and supplies" benefit category. The record shows the provider is out-of-network.
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 to the coinsurance the ECG provided on November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the
lower extremity (73721) provided February 20, 2020.
You asked the Plan to waive the copayment for the MRI. You say that the copayment should be waived. The
Plan denied your request. The Plan says the correct cost-sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for diagnostic tests.
You have been asked to pay a $250 copayment for the MRI. the MRI falls within the diagnostic tests 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 Magnetic Resonance Imaging (MRI) of the
lower extremity (73721) provided February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Valacyclovir HCL 500mg tablet.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Valacyclovir HCL 500mg tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99071) provided on January 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99071 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for these services. 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 services (CPT 99071) provided on January 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on June 5, 2019 through December 18, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says S codes are not payable by Original Medicare.
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 S9328 is not supported in the record. Specifically, per the physician fee schedule, CPT code S9328 has a status code of I. This means that code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on June 5, 2019 through December 18, 2019.