Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments.

You asked the Plan to pre-approve the IVIG treatments. You say that it is felt that this is medically necessary. The Plan denied your request. The Plan says the criteria for continuation of IVIG treatment are not met.

The Plan follows Medicare rules. Medicare rules say that IVIG treatment for myasthenia gravis is considered medically reasonable and necessary when the above criteria are met. 

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 IVIG treatments. Our reviewer says that the requested treatment is not shown to be medically necessary based on LCD guidelines. Our physician reviewer found per the documentation, the enrollee has a history of both Myasthenia Gravis and multiple sclerosis (the latter for which the member was on Tecfidera). The member was said not to have had benefit from initial therapy with Prednisone. The member was, as of 02/11/2021, noted to be receiving Intravenous immunoglobulin every 3 weeks. The request has since been made for continued coverage of Intravenous immunoglobulin. 

In this case, the member did not meet the criteria for coverage. The member's clinical presentation did not meet any of the following indications for which intravenous immunoglobulin is covered for Myasthenia Gravis; Acute severe decompensation when other treatments have been unsuccessful or are contraindicated; OR Myasthenia crisis (i.e., an acute episode of respiratory muscle weakness) in patients with contraindications to plasma exchange; OR Chronic debilitating disease in spite of treatment with cholinesterase inhibitors, and/or complications from or failure of steroids and/or azathioprine, OR Periodical use to maintain remission in patients with MG that is not well controlled despite the use of chronic immunomodulating drugs. The review has determined that the enrollee does not meet criteria for coverage of Privigen for the diagnosis of Myasthenia Gravis.

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 IVIG treatments have not been met. Therefore, we decided that the Plan does not have to pre-approve intravenous immune globulin (IVIG) treatments.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the external infusion pump rental provided from April 1, 2020, through June 3, 2020.

You asked the Plan to pay for the infusion pump rental. You say that these claims should be paid due to medical necessity. The Plan denied your request. The Plan says these infusions were started during physician visits. As such, the payment for the equipment is included in the payment made to the provider who began the infusion.

The Plan must follow Medicare rules. Medicare rules say that when drug infusions that require prolonged administration through an external pump are initiated in a physician's office, payment for the drug and the equipment is included in the payment made to the physician or facility.

In this case, the infusion of these chemotherapy drugs in a hospital. Payment for the related equipment cannot be made separately to the equipment supplier as it is included in the payment to the hospital. Therefore, we decided that the Plan does not have to pay for the external infusion pump rental provided from April 1, 2020, through June 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on August 12, 2020 by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that these services were medically necessary. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided 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 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 for physician services provided on August 12, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fitness benefit used on April 1, 2019 through December 4, 2019.

You asked the Plan to pay for the fitness benefit. You say that you would like reconsideration because you submitted your reimbursement request prior to the deadline. The Plan denied your request. The Plan says this reimbursement request was not submitted timely.

Medicare does not pay for this service. For this reason, the Plan's rules apply. The Plan rules say that member requests for reimbursement of qualified membership dues may be submitted monthly but must be received no later than 31 days following the end of the plan year. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the fitness benefit have not been met. Specifically, there is no evidence that this reimbursement request was submitted timely. Therefore, we decided that the Plan does not have to pay for the fitness benefit used on April 1, 2019 through December 4, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305 and 88104 provided on June 29, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 codes 88361, 88312, 88305 and 88104 are not supported in the medical record. Specifically, these codes have a physician Fee Schedule PCTC indicator of A and the claim has a Place of Service (POS) of 22 - Outpatient Hospital. The codes describe a diagnostic procedure that requires a professional component modifier in this POS 22 and have a status indicator of A = Active code. These codes are separately paid under the physician fee schedule if covered. There will be RVUs and payment amounts for codes with this status. The presence of an "A" indicator does not mean that Medicare has made a national coverage determination regarding the service; A/B MACs (B) remain responsible for coverage decisions in the absence of a national Medicare policy. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 88361, 88312, 88305 and 88104 provided on June 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. Medicare rules say that SNF services have specific coverage criteria. Custodial care is not covered. Our Physician Reviewer says that the medical records do not show the enrollee requires skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. Medicare coverage criteria for SNF services are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services are not met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Transthoracic Echocardiogram (TTE) with Doppler Complete (93306) provided July 6, 2020.

You asked the Plan to waive the copayment for the TTE with Doppler Complete. You say that you should not be charged a copayment. The Plan denied your request. The Plan says the service was not considered a follow-up visit and the copayment was charged 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 $40 copayment for each basic imaging service (e.g., general x-rays or ultrasound). 

You have been asked to pay a $40 copayment for TTE with Doppler Complete. TTE with Doppler Complete 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 copayment for the Transthoracic Echocardiogram (TTE) with Doppler Complete (93306) provided July 6, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay a higher amount for two psychiatrist visits (99214, 90792) provided on August 5, 2020, to September 4, 2020.

You asked the Plan to pay a higher amount for two psychiatrist visits. You say that you expected to be reimbursed for the full amount you paid for these services. The Plan denied your request. The Plan says these services 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 $30 copayment for each Medicare-covered individual or group therapy visit with a psychiatrist. Your contract with the Plan also says that if you pay the entire amount yourself at the time you receive covered services, the Plan will reimburse you for its share of the cost. 

You have been asked to pay a $30 copayment for each of two psychiatrist visits. The Plan has reimbursed you for the allowed amount minus this copayment, which means they have paid their share of the cost. 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 pay a higher amount for two psychiatrist visits (99214, 90792) provided on August 5, 2020, to September 4, 2020.

Your complaint about the amount you paid for these services that exceed the allowed amount is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999), the electroencephalogram (EEG) during surgery (95955), the continuous intraoperative neurophysiology monitoring (95940), the somatosensory testing (95938), and the nerve conduction studies (95908) provided on March 5, 2019.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services are not payable as the claim was submitted untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for these services was not filed until July 30, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999), the electroencephalogram (EEG) during surgery (95955), the continuous intraoperative neurophysiology monitoring (95940), the somatosensory testing (95938), and the nerve conduction studies (95908) provided on March 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on October 8, 2020.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that the device did not properly fit and you ended up purchasing a different device. 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 DME and related supplies. You received DME and related supplies on October 8, 2020. The total allowed amount is $662.49 and 20% of that is $132.49. 

You have been asked to pay the total coinsurance amount of $132.49 for DME and related supplies. DME and related supplies fall within the 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 pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office and outpatient hospital visits provided January 1, 2020 to November 8, 2020.

You asked the Plan to pay for the outpatient visits. You say that you are appealing the amounts of your share payment for all services you have received thus far in the year 2002. Please review all the amounts of your share due to different medical providers. The Plan denied your request. The Plan says as of November 30, 2020, you have paid $6,459.18 towards your $7,400 yearly plan deductible.

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 there is $7,400 yearly deductible. This is the amount you must pay before the plan pays for their share. 

The item or service you asked the Plan to pay for falls within the benefit category Deposit and Deductible Amounts. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $7,400 yearly deductible. This is the amount you must pay before the plan pays for their share. This cost sharing is a contractual obligation that had not been met at the time the outpatient visits was received on January 1, 2020 to November 8, 2020. Therefore, we decided that the Plan does not have to pay for the outpatient office and outpatient hospital visits provided January 1, 2020 to November 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor supplies rendered on September 19, 2020.

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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. 

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the continuous glucose monitor supplies rendered on September 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services for the enrollee.

You asked the Plan to pre-approve IRF services. You say that these services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. The Plan must follow Medicare rules. Medicare rules say that IRF services have specific coverage criteria. Our Physician Reviewer says that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There also is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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 services are not met. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computed tomography, thorax; without contrast material.

You asked the Plan to waive the copayment for a CT scan. You say that you had two CT scans completed on September 23, 2020, and you want to pay one copayment. The Plan denied your request. The Plan says there is a $275 copayment for each advanced imaging service and the copayment was 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 advanced imaging service. 

You have been asked to pay a $275 copayment for a CT scan. A CT scan falls within the outpatient 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 a computed tomography, thorax; without contrast material (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on October 26, 2020.

You asked the Plan to pay for an annual wellness visit. You say that you have never been charged for an AWV and cannot afford this charge. The Plan denied your request. The Plan says you previously had an AWV in February of 2020.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on October 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 16, 2020.

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 14060 is not supported.

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 14060 is adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less. 

We find that CPT code 14060 is not supported in the medical record. Specifically, the operative report does not document an adjacent tissue transfer of the eyelids, nose, ears, and/or lips of 10 sq cm or less. 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 pay for the surgical services rendered on July 16, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 20, 2020.

You asked the Plan to pay for the subsequent nursing facility care. You say that the physician provided medically necessary services to this enrollee in good faith. 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 enrollee's terminal condition.

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 the subsequent nursing facility care provided on March 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on October 27, 2020.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges. 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 a $35 copayment for outpatient rehabilitation services. 

You have been asked to pay a $35 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 outpatient rehabilitation services provided on October 27, 2020.