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

We decided that the Plan does not have to waive the copayment for the outpatient specialty physician visit.

You asked the Plan to waive the copayment for the outpatient specialty physician visit. You say that the visit
should be considered preventative, therefore no copayment should apply. The Plan denied your request. The
Plan says the correct cost share 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 $45
copayment for outpatient hospital services.

You have been asked to pay a $45 copayment for the outpatient specialty physician visit. The outpatient
specialty physician visit falls within the outpatient hospital services benefit category. The outpatient specialty
visit was billed separately from the preventative health service. 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 outpatient specialty physician visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says it is important for the enrollee to know which providers are part of our network because, with limited exceptions, the enrollee must use network providers to get medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services and cases in which the Plan authorizes use of out-of-network providers.

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 physician's services. We found no exception that would require the Plan to pay for the physician's services. Therefore, we decided that the Plan does not have to pay for physician's services that you provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided.You asked the Plan to pay forhome infusion therapy. You say that this code hasbeen paid in the past.The Plan denied your request. The Plan says this code is not valid for 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 medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided .
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forportable X-Ray services provided  by an out of network (OON) provider.You asked the Plan to pay forX-Ray. You say that these procedures do not require prior authorization.The Plan denied your request. The Plan says the denial of payment for these services is correct, because prior authorization was not obtained.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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service 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 forportable X-Ray services provided  by an out of network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the head (70450).

You asked the Plan to pay for the CT scan. You say that the services were medically necessary. The Plan denied your request. The Plan says this CPT code shares a bundled relationship with another code billed and is not eligible for separate payment.

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 70450 has a column I / column II relationship with code 70496 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 computed tomography (CT) of the head (70450).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services.

You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not
urgent or emergent, nor were they approved in advance.

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
diagnostic radiology services. 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 diagnostic radiology services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist office visit (99205) provided.You asked the Plan to waive the copayment fora specialist office visit. You say that this should be fully covered.The Plan denied your request. The Plan says this processed 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 $25 copayment for specialist office visits. You have been asked to pay a $25 copayment for a specialist 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 fora specialist office visit (99205) provided
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the medical services.

You asked the Plan to pay for the medical services. You say that you would like reconsideration because you went to an in-network facility. The Plan denied your request. The Plan has not provided any evidence that they have addressed your argument.

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. Specifically, the Plan has failed to forward any information regarding their denial of these services. It is the burden of the Medicare Health Plan to substantiate the denial with evidence. The denial is not substantiated and we must find in your favor. Therefore, we decided that the Plan has to pay for the medical services.

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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve Evenity.

You asked the Plan to pre-approve Evenity. You say that the enrollee has chronic pain, multiple falls, multiple fractures of the spine and neck, is a fall risk, and has a diminished quality of life. The Plan denied your request. The Plan says that the enrollee has not tried any of the preferred agents and has not shown to have contraindications to these preferred products.

The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage plans must establish policies and procedures to educate and information health care providers and enrollees concerning its step therapy policies.

We looked at the file and Medicare rules. The information provided by the Plan did not show an Evidence of Coverage or Annual Notice of Change clearly disclosing that Part B drugs may be subject to step therapy requirements. Based on this information, we decided that Medicare rules for coverage of Evenity have been met. Therefore, we decided that the Plan has to pre-approve Evenity.

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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forpsychotherapy provided by an out-of-network provider You asked the Plan to pay forpsychotherapy. You say that the facility failed to obtain the necessary authorization. You say that the physician provided medically necessary services and the claim should be processed for payment.The Plan denied your request. The Plan says authorization for out of network services was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says thatthe 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan doesnot have to pay forpsychotherapy provided by an out-of-network provider .
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe darbepoetin alfa injection (J0881 and 96372) provided .You asked the Plan to pay forthe darbepoetin alfa injection. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not support the services 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 J0881 is injection, darbepoetin alfa, 1 microgram (non-ESRD use).The CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. We asked our coder 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 darbepoetin alfa injection. Our reviewer says that CPT codes J0881 and 96372 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that an Injection, darbepoetin alfa, 1 microgram (non-ESRD use) (200 units) administered bytherapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular was provided , therefore this service cannot be verified.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the darbepoetin alfa injection have not been met.Therefore, we decided that the Plan does not have to pay forthe darbepoetin alfa injection (J0881 and 96372) provided
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe external defibrillator provided .You asked the Plan to waive the coinsurance forthe external defibrillator. You say that you were never told you would be responsible for some of the bill. You say that you want to be absolved of the bill.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 durable medical equipment from a durable medical equipment provider.You have been asked to pay $585.12, which is 20% of the allowed amount for the external defibrillator. The allowed amount is $2,925.60 (20% x $2,925.60 = $585.12). The external defibrillator 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 paywhen you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe external defibrillator provided .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Supartz injection.

You asked the Plan to pre-approve the requested services. You say that the enrollee has had this treatment in the past. The Plan denied your request. The Plan says the enrollee's diagnosis is not supported by the documentation.

The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee is only covered under certain medical indications.

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 requested services. Our physician reviewer found that the enrollee has bilateral knee osteoarthritis. She uses a walker and pain interferes with activities of daily living. Conservative therapy, with oral medication and steroid injections, were not effective. The first Supartz injection only had 20% improvement. Her x-rays show osteopenia and maintained joint spaces. The x-ray documentation does not indicate that the enrollee has osteoarthritis. The enrollee does not meet the coverage criteria. Therefore, the requested service cannot be considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Supartz injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of care with a tertiary level of care provider.

You asked the Plan to pre-approve a tertiary level of care. You say that you have been going to this tertiary provider for 3 years now. You say that your cancer has grown quite a bit and that it spreads fast. The Plan denied your request. The Plan says the criteria for coverage of OON tertiary level care have not been met. The Plan says that the services can be done at a non-tertiary level of care.

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 pre-approve a tertiary level of care. Our reviewer says that a tertiary level of care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has malignant neoplasm. The documentation does not show that there is anything unique about the enrollee's condition that makes it medically necessary to receive care at the tertiary level. The Plan has shown that they have non-tertiary providers within their network who meet the Standards of Care required for treatment of the enrollee's condition.

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 tertiary level of care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of care with a tertiary level of care provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAbraxane 100 mg for suspension.You asked the Plan to pre-approveAbraxane. You say that this drug is medically necessary to treat the enrollee's condition.The Plan denied your request. The Plan says there is no support for using this drug for the enrollee's medical condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Abraxane. Our reviewer says that the requested drug is not medically necessary and reasonable for the enrollee's condition. Our physician reviewer found based off the record in the Medicare-approved compendia, this request for Abraxane to treat the enrollee's lung cancer does not meet requirements. Specifically, Epidermal growth factor receptor (EGFR) and anaplastic large-cell lymphoma kinase(ALK) are unknown in this scenario when they need to be wild type according to the compendia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met.Therefore, we decided that the Plan does not have to pre-approveAbraxane 100 mg for suspension.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a procedure (20520).

You asked the Plan to pay for the procedure. You say that this service was medically necessary. The Plan denied your request. The Plan says that the documentation does not support the services 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 20520 is Removal of foreign body in muscle or tendon sheath, simple.

We find that CPT code 20520 is supported in the medical record. Specifically, the provided operative report clearly documents the removal of an upholstery staple from the soft tissue of the right foot. Based on this information, we decided that Medicare rules for coverage of the procedure have been met. Therefore, we decided that the Plan has to pay for a procedure (20520).

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 therapy services (CPT 97010) provided to the enrollee.

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 no additional payment can be made for this service, as payment for CPT 97010 has been bundled into the payment.

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 97010 is "hot or cold packs."

We asked our coding 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 services at issue in this case were not supported by the records. Our coding reviewer found Medicare considers the denied code to a bundled service. Therefore, it is not separately billable from primary service rendered.

We looked at this cocer'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 for therapy services (CPT 97010) provided to the enrollee.