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

We decided that the Plan does not have to waive the copayment for urgently needed services provided on November 14, 2020.
You asked the Plan to waive the copayment for urgently needed services. You say that you received a COVID-19 test and thought that it was supposed to be covered. 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 $65 copayment for urgently needed services. The medical records show that you received an urgent care visit on November 14, 2020. Urgent care visits are not included in the waiver. Therefore, you are responsible to pay the $65 copayment. You have been asked to pay a $65 copayment for urgently needed services. Urgently needed services fall within the urgently needed 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 urgently needed services provided on November 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services.

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 codes 37184 and 36245 are 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 37184 is primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel. The definition of code 36245 is selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family.

We find that CPT codes 37184 and 36245 are not supported in the medical record. Specifically, there is no documentation of a primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft to support code 37184. There is no documentation of a selective catheter placement to support code 36245. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the apnea monitor electrodes rendered on September 18, 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 the services were rendered outside of the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The file shows that the services were billed with place of service (POS) code 21 for an inpatient hospital. Medicare does not separately cover DME for use outside of the home. Therefore, we decided that the Plan does not have to pay for the apnea monitor electrodes rendered on September 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on August 27, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that when conducting a review of a covered DME item ordered by a physician, the Plan shall ensure that the physician saw the enrollee (including through the appropriate use of telehealth) and conducted a face-to-face assessment. We looked at the file and Medicare rules. The file does not contain documentation showing that the face-to-face encounter included information supporting the enrollee was evaluated or treated for a condition that supports the DME ordered. The file does not document that the face-to-face encounter was made prior to the written order. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on August 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 14, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says these
services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
nurse practitioner services. We found no exception that would require the Plan to pay for these services.
Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on
September 14, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided by an out-of-network provider on
October 1, 2020.
You asked the Plan to pay for the ultrasound. You say that the documentation supports payment for the services
rendered. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 ultrasound provided by an out-of-network
provider on October 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for bronchodilation responsiveness testing (94060) provided on
September 15, 2020.
You asked the Plan to pay for bronchodilation responsiveness testing. You say that this is supported. The Plan
denied your request. The Plan says this is not documented in the records.
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 94060 is bronchodilation responsiveness, spirometry as
in 94010, pre- and post-bronchodilator administration.
We find that CPT code 94060 is not supported in the medical record. Specifically, the submitted medical
records do not include documentation of testing being performed both pre- and post-bronchodilator
administration. Based on this information, we decided that Medicare rules for coverage of bronchodilation
responsiveness testing have not been met. Therefore, we decided that the Plan does not have to pay for
bronchodilation responsiveness testing (94060) provided on September 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-share for the Wrist hand finger orthosis (WHFO) (L3808) and occupational therapy (OT) visits (97165, 97110) provided September 9, 2020, September 14, 2020, and September 21, 2020.
You asked the Plan to waive the cost-share for the WHFO and OT visits. You say that the cost of the services is too high. The Plan denied your request. The Plan says the cost-sharing 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 20% coinsurance for each Medicare-covered durable medical equipment item. It also says that you must pay a $40 copayment for each Medicare-covered outpatient rehabilitation therapy visit. You have been asked to pay a total of $264.43 (($722.16 total allowed amount x 20% coinsurance) + ($40 copayment x 3 therapy visits) = $264.43) for the WHFO and OT visits. The WHFO falls within the Durable medical equipment and related supplies benefit category and the OT visits 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 cost-share for the Wrist hand finger orthosis (WHFO) (L3808) and occupational therapy (OT) visits (97165, 97110) provided September 9, 2020, September 14, 2020, and September 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would prefer to see someone you are comfortable with. The Plan denied your request. The Plan says there are in-network providers available.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve specialist services 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 pay for physical therapy services (97161, 97140, 97530, 97014) provided on August 31, 2020.
You asked the Plan to pay for physical therapy services. You say that these services should be covered. The Plan denied your request. The Plan says these services cannot be paid as 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.
We find that CPT codes 97161, 97140, 97530, and 97014 are not supported in the medical record. Codes 97161 and 97140 were previously billed and paid, and the submitted records do not support additional units. The records also show that a total of 20 minutes of service were performed for codes 97140 and 97530, meaning only one total unit can be billed. Code 97014 has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97161, 97140, 97530, 97014) provided on August 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.

You asked the Plan to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939). You say that the bone marrow aspirate is necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental in cases of spinal fusion surgery. More research is needed to show safety and efficacy of bone marrow aspirate. Iliac crest bone graft is the gold standard.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure) (20939) have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips.

You asked the Plan to pre-approve these services. You say that The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred durable medical equipment suppliers. 

We looked at the file and Medicare rules. The requested services are Accu-Chek test strips. Accu-Chek is not the preferred provider with the Plan. Test strips are available from the Plan's preferred providers. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek Aviva Plus test strips.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for 7 physical therapy visits (97139) provided November 4, 2020 to November 19, 2020.
You asked the Plan to pay for the physical therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says that coverage criteria was not met.
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. In this case, the plan did not forward any clinical documentation to the IRE for review. Furthermore, the Notice of Denial of Medicare Coverage provided in the case file was issued after the dates of service at issue. Therefore, we decided that the Plan has to pay for 7 physical therapy visits (97139) provided November 4, 2020 to November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to IV or oral bisphosphonate such as Reclast or Fosamax.
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 Prolia (J0897). Our reviewer says that the drug is not reasonable and medically necessary. Our physician reviewer found the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. The enrollee does not have a history of osteoporosis related fracture. The enrollee tried Fosamax but had GI side-effects requiring cessation of therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an implantable heart rhythm monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no evidence of true syncope in the clinical documentation.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 monitor. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have symptomatic supraventricular tachycardia (SVT) and possible bradycardia-related symptoms which persist. Although you have not had complete loss of consciousness, you have had near syncope with recurrent symptoms and a prior hospitalization. Further empiric treatment with beta blockers is not indicated given the bradycardia issues. You have already had a prolonged outpatient monitor as recommended in guidelines in the first step in evaluation of these persistent symptoms. This has not been revealing of a specific cause of all your symptoms. At this point, definitive assessment of both tachy and brady arrhythmias which correlate with symptomatology will be most useful is isolating a specific cause and appropriate treatment for the ongoing symptoms. At your age, intermittent tachy/brady arrhythmias from sick sinus syndrome is the most likely cause and a definitive diagnosis and treatment plan is important as you are at high risk for falls, which could be catastrophic at this age. Even in the absence of complete loss of consciousness, the symptoms are significant, possibly life threatening and reasonable prior non-invasive prolonged external monitor evaluations have failed to discern a cause. At this point, an implantable loop recorder is the next most logical diagnostic step with the highest yield and is medically necessary for the management of this condition and meets criteria for medical necessity. 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 monitor have been met. Therefore, we decided that the Plan has to pre-approve an implantable heart rhythm monitor.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services and emergency care.

You asked the Plan to waive the copayment. The Plan denied your request. The Plan says you are responsible
for the cost share.

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 $250
copayment for each one-way Medicare-covered ambulance transport. Your contract also clearly says that you
must pay a $90 copayment for each emergency room visit.

Review of the file shows that you were provided ambulance transportation and emergency room services. 
You have been asked to pay a $250 copayment for ambulance services, and a $90 copayment for the 
emergency room services. 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 ambulance services 
and emergency care
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy session (90832) provided by an out of network (OON) provider.

You asked the Plan to pay for the psychotherapy. You say that this was a medically necessary service. The Plan denied your request. The Plan says they do not cover out of network services, except in limited circumstances. The service at issue was not urgent or pre-approved and 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 the psychotherapy session (90832) provided 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 periapical x-rays provided to the enrollee on October 8, 2020.
You asked the Plan to pay for the x-rays. The Plan denied your request. The Plan says this is not a covered benefit.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. The Plan only covers cleanings, oral exams, bitewing x-rays, fillings, and extractions. Periapical x-rays are not covered. Therefore, we decided that the Plan does not have to pay for the periapical x-rays provided to the enrollee on October 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the collection and application of autologous blood concentrate product (D7921), non-intravenous conscious sedation (D9248), and consultation (D9310).

You asked the Plan to pay for the collection and application of autologous blood concentrate product, non-intravenous conscious sedation, and consultation. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services are not covered under the Plan.

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.

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 the collection and application of autologous blood concentrate product (D7921), non-intravenous conscious sedation (D9248), and consultation (D9310).