Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 15, 2019 to November 3, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 15, 2019 to November 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (90837) provided on July 1, 2019 by out of network provider.
You asked the Plan to pay for psychotherapy. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service July 1, 2019. You recently obtained authorization. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. They did not authorize any services for this provider. There are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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. Even though you obtained authorization for this patient, the effective date was August 14, 2019 which is after the date of service July 1, 2019. The Plan has network providers available who can provide 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 for psychotherapy (90837) provided on July 1, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on September 20, 2019 by
out of network provider.
You asked the Plan to pay for a specialist office visit. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that there are in-network providers available for these services.
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 has network providers
available who can provide 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 for a specialist office visit provided on September 20,
2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on August 19, 2019 by an out of network provider.
You asked the Plan to pay for outpatient lab work. You say that these services are provided in good faith. You say that you were not aware prior authorization was required. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 has network providers available who can provide 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 for outpatient lab work provided on August 19, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Orthovisc 15mg/ml syringe for the
enrollee.
You asked the Plan to pre-approve the tier exception. You say that this is medically necessary. The Plan denied
your request. The Plan says tier exceptions are only possible for certain Part D drugs.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D
drugs.
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for
coverage of the tier exception have not been met. Therefore, we decided that the Plan does not have to preapprove
a tier exception for Orthovisc 15mg/ml syringe for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 30 minutes of advance care planning (99497) provided on
July 31, 2019.
You asked the Plan to pay for the advance care planning. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the submitted medical records do not
indicate that advance care planning including the explanation and discussion of advance directives such as
standard forms, by the physician or other qualified health care professional; first 30 minutes, face-to-face with
the patient, family member(s), and/or surrogate was performed.
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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the record. Specifically, the record does not indicate that 30
minutes of advance care planning was rendered. Based on this information, we decided that Medicare rules for
coverage of the advance care planning have not been met. Therefore, we decided that the Plan does not have to
pay for 30 minutes of advance care planning (99497) provided on July 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for radiation therapy provided from August 6, 2019 to August 7, 2019.
You asked the Plan to waive the coinsurance for radiation therapy. You say that you were not informed that you would owe such a high amount. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 20% coinsurance for each radiation therapy service. You received radiation therapy from August 6, 2019 to August 7, 2019. The total allowed amount is $8,410.96 and 20% of that is $1,682.19. You have been asked to pay the total coinsurance amount of $1,682.19 for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for radiation therapy provided from August 6, 2019 to August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require daily medical management for complex medical or rehab issues.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our physician reviewer found that the enrollee's current level of function is ambulation with contact guard assist, sit-to-stand with minimal assist, and needs encouragement with activities of daily living due to weakness. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapy, but she does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility (SNF) care (99308) provided on
September 11, 2019 by an out of network provider.
You asked the Plan to pay for subsequent nursing facility care. You say that you are appealing the denied claim
for service. The Plan denied your request. The Plan says the provider is not an in-network provider and
there is no authorization on file. The service was not plan-directed and there is no facility claims.
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 has network providers
available who can provide 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 for subsequent nursing facility (SNF) care (99308)
provided on September 11, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pain management services to be provided to the enrollee by out of network provider.
You asked the Plan to pre-approve the out-of-network services. You say that in-network offices charge a surgical fee, which the enrollee cannot afford. The Plan denied your request. The Plan says the service requested is available in-network.
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 pre-approved care. 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 out-of-network services. Therefore, we decided that the Plan does not have to pre-approve the pain management services to be provided to the enrollee by an out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from September 4, 2019 through September 5, 2019.
You asked the Plan to waive the copayment for the observation stay. You say that you were informed you would only have a $90 copayment. You say that the bill should be revised. 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 $275 copayment for each Medicare-covered visit to an ambulatory surgical center or outpatient hospital facility for hospital services. Covered services include services in an emergency department or outpatient clinic, such as observation services or outpatient surgery. You have been asked to pay a $275 copayment for the observation stay. The observation stay falls within the "Outpatient hospital services" 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 the observation stay provided from September 4, 2019 through September 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the ambulance transports provided on July
4, 2019 and July 5, 2019 and the office visit provided on August 2, 2019.
You asked the Plan to waive the copayments for the ambulance transports and office visit. You say that you
were in an accident. You say that you should not have to pay any of the bills. The Plan denied your request.
The Plan says the copayments 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 $25
copayment for each Medicare-covered one-way trip and a $5 copayment for each in-network primary care
doctor visit for Medicare covered benefits.
You have been asked to pay a total of $55 for the ambulance transports and office visit.
The ambulance transports fall within the "Ambulance Services" benefit category. The office visit falls within
the "Physician/Practitioner services, including doctor's office visits" 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 copayments for the ambulance transports provided on July 4, 2019 and July 5, 2019
and the office visit provided on August 2, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on September 26, 2019.
You asked the Plan to pay for the ambulance services. You say that the enrollee was discharged from the hospital to go to a skilled nursing facility for treatment and rehabilitation. You say that the enrollee was seen for urinary tract infection and altered mental status which is not hospice related. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.
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. The record shows proof of hospice election from September 26, 2019 to October 9, 2019. Therefore, we decided that the Plan does not have to pay for ambulance services provided on September 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthovisc injections in the left knee (J7324).
You asked the Plan to pre-approve orthovisc injections in the left knee. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's left knee does not meet Medicare criteria.
The Plan follows Medicare rules. Medicare rules say that Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when radiologic evidence of osteoarthritis of the knee. 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 orthovisc injections in the left knee. Our reviewer says that orthovisc injections in the left knee are not medically necessary at this time. Our physician reviewer found x-ray results of the left knee were normal, showing no evidence of osteoarthritis. The records do not clearly show that other diagnoses had been excluded.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of orthovisc injections in the left knee have not been met. Therefore, we decided that the Plan does not have to pre-approve orthovisc injections in the left knee (J7324).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on September 2, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care. The enrollee has been asked to pay a $90 copayment for an ER visit. An ER visit falls within the emergency care 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 ER visit provided on September 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on October 1, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the denied claim as the notes will support medical necessity. The Plan denied your request. The Plan says the rendering provider is a non-participating provider. The plan did not authorize any services for the doctor who is a non-participating provider. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 has network providers available who can provide 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 for an office visit (99214) provided on October 1, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on July 12, 2019 by out of network provider.
You asked the Plan to pay for outpatient lab work. You say that you performed these services in good faith. You say that these services were provided based on the request from the referring provider. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 has network providers available who can provide 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 for outpatient lab work provided on July 12, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injection for the enrollee.
You asked the Plan to pre-approve facet joint injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that injections are only covered for certain 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 facet joint injection. Our reviewer says that the documentation does not support that the requested injection services are medically reasonable or necessary. Our physician reviewer found the enrollee has chronic low back pain. The enrollee takes oxycodone, methocarbamol and diazepam. The enrollee has failed Physical therapy. The enrollee had a radiofrequency ablation performed with apparent success but the degree and duration of the pain relief is not documented. Therefore, the requested procedure cannot be deemed medically reasonable or 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 facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injection.