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

We decided that the Plan does not have to pay for subsequent hospital care services (CPT 99233).

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 this code was received with a secondary diagnosis code as the principal or primary diagnosis.

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 99233 is "subsequent hospital care/day, 35 minutes."

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 medical records. Our coding reviewer found the provider billed ICD 10 G63 Toxic encephalopathy for primary diagnosis (which by definition is caused by a drug or toxin and requires that a "T" code is reported). A code from T36 - T50 or a code from T51 - T65 is not required and sequenced first, before G92 Toxic encephopathy unless a drug or toxic agent is applicable to the case and documented as the etiology of the toxic encephalopathy. In this case provider documents "unsure of etiology but is much better today 7/1", therefore, it would be appropriate to code encephalopathy other or/and unspecified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care services (CPT 99233) provided to the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa for the enrollee.

You asked the Plan to pre-approve this drug. You say that the patient would benefit from this drug. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Vascepa for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility services.

You asked the Plan to pay for the skilled nursing facility services. You say that the services were medically necessary. The Plan denied your request. The Plan says that they failed to make a decision in a timely manner.

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. There are no medical records in the case file. Therefore, we decided that the Plan has to pay for skilled nursing facility 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Emgality.

You asked the Plan to pre-approve Emgality. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not include Part D prescription coverage. Therefore, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Emgality.

Benefits for Emgality may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the sonogram.

You asked the Plan to waive the coinsurance for the sonogram. You say that you were not aware of the coinsurance for this service. You say you have never paid for this service in the past. 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 20% coinsurance for up to a maximum of $75 per day for Medicare-covered diagnostic radiology services.

You have been asked to pay $26.55 which is 20% of the allowed amount for the sonogram. The allowed amount is $132.76. ($132.76 x 20% = $26.55). The sonogram 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 the sonogram.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from September 23, 2020,
through October 21, 2020, by non-participating providers.

You asked the Plan to pay for the medical services. You say that the claims should be paid. The Plan denied
your request. The Plan says prior authorization was not obtained by the provider or facility. The Plan states the
provider should have verified the enrollee's eligibility, health benefits and obtained authorization prior to the
enrollee's visit before providing services to the enrollee as outlined on the enrollee's ID card.

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 the medical services provided from September 23,
2020, through October 21, 2020, by non-participating providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B drugs provided from September 17, 2019, to October 14, 2020.

You asked the Plan to waive the coinsurance for the Part B drugs. You say that you should not be responsible for the coinsurance because you have never had to pay for the shots before. 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs. 

You have been asked to pay a total of $55.36 for the Part B drugs. The Part B drugs falls within the "Medicare Part B prescription drugs" 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 the Part B drugs provided from September 17, 2019, to October 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for a treatment program (HCPCS H2036).

You asked the Plan to pay for the program. You say that this should be paid for. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.

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 HCPCS code H2036 is "Alcohol and/or other drug treatment program, per diem."

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the program. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found HCPCS H2036 is an inappropriate code to use for residential inpatient alcohol and/or drug treatment program. A more comprehensive code should be used to report services. When reporting services, CPT/HCPCS codes should be coded to the highest specificity for Medicare to confirm coverage criteria have been 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 the program have not been met. Therefore, we decided that the Plan does not have to pay for a treatment program (HCPCS H2036) provided to the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the documentation does not support that skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse is required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. Skilled services are not needed on a daily basis or as practical matter in a skilled nursing facility setting. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the elbow orthosis purchased on July 22, 2020.

You asked the Plan to reimburse you for the elbow orthosis. You say that you needed the elbow orthosis to
improve your life. The Plan denied your request. The Plan says you obtained durable medical equipment from a
provider who does not participate with Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items provided directly by a provider who is not eligible to take Medicare payment.

The item at issue in this appeal was provided by a provider not certified by Medicare. Therefore, we decided
that the Plan does not have to reimburse you for the elbow orthosis purchased on July 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the colonoscopy or the laboratory work provided on October 1, 2020.

You asked the Plan to waive the cost share for the colonoscopy and the laboratory work. You say that you feel this was a routine service and no copayment should have been applied. 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 $200 copayment for ambulatory surgical center and outpatient hospital visits and 10% coinsurance laboratory tests. 

You have been asked to pay a total of $208.96 for the colonoscopy and the laboratory work. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows two polyps were removed and tested, which makes the colonoscopy diagnostic in nature.

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 cost share for the colonoscopy or the laboratory work provided on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

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 claim was received past the allowed 12 month timeframe.

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 the services was not filed until August 27, 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 services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

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 claim was filed past the timeframe.

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 the services was not filed until September 8, 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 services provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial nursing facility care services provided on March 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the initial nursing facility care services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 the initial nursing facility care services provided on March 11, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found it is not medically reasonable and necessary to
provide skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis." You
do not require the necessary services on an inpatient basis, in a skilled nursing facility setting.

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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lens fitting (CPT Code 92310) provided by an out-of-network provider.

You asked the Plan to pay for the contact lens fitting. You say that you have never been denied coverage for the fitting and follow-up. The Plan denied your request. The Plan says services for contact lenses and or fitting are not covered by an out-of-network provider.

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 $150 plan coverage limit includes new eyeglasses, contact lenses, lens replacement, fitting, adjustment or repair. Must be purchased from a network supplemental vision provider. As you received Contact lenses purchased online from an out-of-network provider, the services denied appropriately for the date of service. 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 the contact lens fitting (CPT Code 92310) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames and lenses (V2025, V2750, V2781, V2784) provided October 2, 2020.

You asked the Plan to pay for the eyewear. You say that the eyewear should be covered. The Plan denied your request. The Plan says the glasses purchased are not standard frames with conventional lenses. Upgraded features are not covered.

The Plan must follow Medicare rules. The rules say that Medicare covers one pair of conventional eyeglasses or contact lenses furnished after each cataract surgery with insertion of an IOL. 

The eyewear you asked the Plan to pay for includes upgraded features such as Deluxe Frames and Anti-reflective lenses. Coverage is limited to one pair of conventional eyeglasses with standard lenses and frames. Therefore, we decided that the Plan does not have to pay for eyeglass frames and lenses (V2025, V2750, V2781, V2784) provided October 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for F1Heme testing provided on August 21, 2020.

You asked the Plan to pay for the F1Heme testing. You say that you would like reconsideration because this
testing is medically necessary. The Plan denied your request. The Plan says this service was not billed
correctly.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the F1Heme testing. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found a comprehensive panel is not supported by the NCCN Guidelines unless there is possible
Richter's transformation. There is no indication from the records that the member has Richter's transformation.

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 F1Heme testing have not been met. Therefore, we decided that the Plan
does not have to pay for F1Heme testing provided on August 21, 2020.