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

We decided that the Plan does not have to waive the copayment for the blood vessel imaging procedure provided on November 6, 2019.
You asked the Plan to waive the copayment for the blood vessel imaging procedure. You say that you are on a fixed income and would have never had this done had you known there would be an additional cost. 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 a $170 copayment for each covered diagnostic procedure or test at a network outpatient facility. You have been asked to pay a $170 copayment for the blood vessel imaging procedure. The blood vessel imaging procedure 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 blood vessel imaging procedure provided on November 6, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder arthroscopy and shoulder orthosis provided to the
enrollee on December 4, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do 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 the denied codes is:
CPT 29806:
arthroscopy, shoulder, surgical; capsulorrhaphy
HCPCS L3670:
shoulder orthosis (SO), acromioclavicular (canvas and webbing type), prefabricated, off-the-shelf
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 coded correctly. Our coding reviewer found CPT 29806 does not meet
criteria for billing or reimbursement consideration. When a CPT code is submitted with a 22 modifier,
indicating increased procedural services the following is required: When the work required to provide a service
is substantially greater than typically required, it may be identified by adding modifier 22 to the usual
procedure code. Documentation must support the substantial additional work and the reason for the additional
work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical
and mental effort required). The medical records provided does not include documentation of an Arthroscopy,
shoulder, surgical; capsulorrhaphy with increased procedural services being performed on December 4, 2019,
therefore this service cannot be verified. Additionally, HCPCS L3670 does not meet criteria for billing or
reimbursement consideration. The medical records provided do not include a valid physician order for a
shoulder orthosis (SO), acromioclavicular (canvas and webbing type), prefabricated, off-the-shelf nor does is
document that one was dispensed on December 4, 2019, therefore this service/supply 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for shoulder arthroscopy and shoulder orthosis provided to the enrollee on December 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).
You asked the Plan to pre-approve Keytruda. You say that Keytruda is medically necessary. The Plan denied
your request. The Plan says the drug has not been proven effective for the enrollee's 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 Keytruda. Our reviewer says that
Keytruda is not medically necessary in this case. Our physician reviewer found Keytruda has not been
demonstrated to be effective for treatment of papillary carcinoma in the medical literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda (J9271).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz/Hyalgan injections (J7231). You asked the Plan to pre-approve Supartz/Hyalgan injections. You say that this drug is your preferred product.The Plan denied your request. The Plan says the enrollee has not tried the Plan's preferred alternatives.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Supartz/Hyalgan injections. Our reviewer says that the criteria for coverage of Supartz/Hyalgan injections have not been met. Our physician reviewer found the Plan requires a trial of drugs Synvisc/Synvisc-One, Durolane, and Gelsyn-3 before they will approve the requested drug. The provided medical records do not indicate that the patient has tried and failed the required drugs or that the required drugs would likely be less effective or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz/Hyalganinjections have not been met.Therefore, we decided that the Plan does not have to pre-approve Supartz/Hyalgan injections (J7231).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee is ready for the next level of care.The Plan denied your request. The Plan says the services are not necessary for the enrollee.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the medical records provided show that the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require skilled physical therapy and occupational therapy but based on the medical records provided the patient does not require treatment in an intensive rehabilitation therapy program.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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair power seat elevation feature.You asked the Plan to pre-approve a power seat elevation feature (E2300). You say that the enrollee needs a Group 3 power wheelchair, accessories, and power seat elevation feature.The Plan denied your request. The Plan says power seat elevation features do not serve a medical purpose and cannot be covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Power seat elevation features are not covered by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair power seat elevation feature.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on February 20, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you would not have a copayment because this was a follow-up to your surgery. You say you could have gone to an urgent care facility instead of the emergency room. 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 a $65 copayment for each in and out-of-network emergency room visit. You have been asked to pay a $65 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure. 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 emergency room visit provided on February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home health visit provided on December 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a home health visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these services were not referred. The Plan says that no prior authorization was 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 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 home health visit provided on December 31, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says care could be received in another setting, such as a skilled nursing facility, outpatient setting or home health care.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 reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted and reasonable period.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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for transfer are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records show the enrollee is currently receiving appropriate care which for which he will likely need acute care for a short time until stable for discharge to a lower level of care. There was no indication that the enrollee would require acute care needs for more than 25 days, according to the notes. There are no services available at the LTACH that the patient needs that is not available and covered at the current acute care facility. Therefore, this request for LTACH transfer is not sufficiently supported and will be considered not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for laboratory services provided on December 30, 2019.You asked the Plan to waive the coinsurance for laboratory services. You say that you disagree with the out-of-network 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 50% coinsurance for out-of-network laboratory tests. You received laboratory services from an out-of-network provider on December 30, 2019. The allowed amount is $2.94 and 50% of that is $1.47. Please contact the provider with any questions regarding overpayments or refunds. You have been asked to pay the total coinsurance amount of $1.47 for laboratory services. Laboratory services fall 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 laboratory services provided on December 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient mental health services (99213, 90792, 90791) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the outpatient mental health services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are non-emergent. There are network providers available who can provide the services at issue.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 care that cannot be provided by network providers.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 services.Therefore, we decided that the Plan does not have to pre-approve the outpatient mental health services (99213, 90792, 90791) to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe outpatient physical therapy services (97110, 97530, G0283, 97140, 97010, 97162, 97112, 97035, 97164, 97535, 97116) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe outpatient therapy services. You say that the services are medically necessary.The Plan denied your request. The Plan says these services are non-emergent and 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 care that cannot be provided by network providers.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 foundno exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvethe outpatient physical therapy services (97110, 97530, G0283, 97140, 97010, 97162, 97112, 97035, 97164, 97535, 97116) to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from December 12, 2019 to December 31, 2019. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly. The Plan must follow Medicare rules. The rules say that where required by law or regulation, report the Federal Information Processing Standards (FIPS) State and County Code of the place of residence where the home health service is delivered with code 85. We looked at the file and Medicare rules. The claims were not billed with the required FIPS code. 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 home health services rendered from December 12, 2019 to December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided by a participating provider on January 27, 2020.
You asked the Plan to waive the copayment for an MRI. You say that you do not know why you are paying so much for this. The Plan denied your request. The Plan says the correct copayment has been 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 $275 copayment for outpatient diagnostic tests/advanced imaging services/outpatient hospital. You have been asked to pay a $275 copayment for an MRI. The correct copayment has been applied to the services that were provided. An MRI falls within the outpatient diagnostic tests/advanced imaging services/outpatient hospital 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 an MRI provided by participating provider on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam (D0140) bone replacement graft (D7953) surgical extraction (D7210) provided April 9, 2020.
You asked the Plan to pay for the dental services. You say that you were not able to wait to see an in-network provider. Your tooth broke and you were in pain. This provider did not take your insurance but you needed the broken tooth removed. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Dental services must be received from an in-network dental provider. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for limited oral exam (D0140) bone replacement graft (D7953) surgical extraction (D7210) provided April 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report rendered on December 18, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 93010 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only.We find that CPT code 93010 is not supported in the medical record. Specifically, there is no documentation of an interpretation and report of an EKG. 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 forthe electrocardiogram (EKG) interpretation and report rendered on December 18, 2019.