Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional extractions provided on October 30, 2019.
You asked the Plan to pay for the two additional extractions. You say that 50% of two extractions should have
been allowed, per your benefits chart. The Plan denied your request. The Plan says your plan only provides
coverage for two extractions per calendar year.
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, extractions are limited to two
procedures per calendar year. The record shows that you received four extractions on October 30, 2019, two of
which were covered at 50% by the Plan, and you are responsible for the additional two extractions because
your extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the
two additional extractions provided on October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive medicine exam rendered to you on August 21, 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 99397 is not covered. The Plan must follow Medicare rules. The rules say that a status indicator of N represents a non-covered service. The provider submitted a claim for procedure code 99397. This code has a status indicator of N and is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the preventive medicine exam rendered to you on August 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you would like to see this provider for low vision. The Plan denied your request. The Plan says there is no documentation of the enrollee seeing an in-network provider for vision issues.
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 a referral to an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 12, 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 Current Procedural Terminology (CPT) code 80307 and HCPCS code G0482 remains 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. We find that the denied codes not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.You asked the Plan to pre-approve the Retacrit. You say that Retacrit is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says Medicare's compendia do not support using this drug for the member's condition.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the Retacrit. Our reviewer says that the requested use of this drug is not FDA approved or supported by any of the major drug compendia for the enrollee's diagnosis. Our physician reviewer found the use of this drug is not supported by relevant clinical research.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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy provided on December 6, 2019 and December 9, 2019.
You asked the Plan to waive the copayments for radiation therapy. You say that you cannot afford 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 $60 copayment for radiation therapy. You received radiation therapy on December 6, 2019 and December 9, 2019 for a total of 2 visits. Therefore, you are responsible to pay a $60 copayment per each visit. The total amount you owe is: $120. You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for radiation therapy provided on December 6, 2019 and December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the monitor. You say that you need this, as you are not able to leave the house due to COVID-19. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac sodium gel.You asked the Plan to pre-approveDiclofenac sodium gel. You say that the medication is necessary.The Plandenied your request. The Plan says based on the documentation provided, the criteria for self-administered drug coverage 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-approveDiclofenac sodium gel.Benefits for Diclofenac sodium gelmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the refraction services (92015) provided on October 18, 2019. 
 
You asked the Plan to pay for the refraction services (92015). You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says that the services are not covered. 
 
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. Specifically, the Plan is denying payment for the refraction services on the basis that the provider did not bill for an eye exam and refraction services are not paid on their own. However, the file does not show that the Plan made any attempts to obtain medical records to determine if the enrollee actually received an eye exam. The file only includes an itemized bill from the provider that states an eye exam was provided. In order to determine if an eye exam took place, the Plan should have requested medical records and the file does not show that the Plan did this. We find that the Plan has not substantiated their reasoning for denial. Therefore, we decided that the Plan has to pay for the refraction services (92015) provided on October 18, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after March 22,
2020.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs additional therapy to walk again.
The Plan denied your request. The Plan says that that the enrollee no longer require skilled services.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before
the last covered day. This notice must include a description of the enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before March 22, 2020. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pre-approve continued skilled nursing facility (SNF) services after March 22, 2020.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the air transport provided on January 9, 2019. You asked the Plan to waive the copayment for the air transport. You say that this was a life-threatening scenario. You say that this should be covered in full.The Plan denied your request. The Plan says the copayment applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment for each one-way Medicare-covered air transportation service. The enrollee has been asked to pay a $300 copayment for the air transport. The air transport falls within the "Ambulance services" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the air transport provided on January 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on March 27, 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 Healthcare Common Procedure Coding System (HCPCS) code G0481 (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on March 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on January 31, 2019.
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services have not been met.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided on January 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered to the enrollee on October 29, 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 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 71045 and 32557. Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 32557. Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered to the enrollee on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for observation care discharge day management services provided to the
enrollee on July 29, 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 that the claim was denied for inconsistent place of service.
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.
Medicare rules also 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 99217 is "Observation care
discharge day management."
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 services. Our reviewers says that the
services at issue in this case were not coded correctly. Our physician reviewer found CPT code 99217 was
billed with place of service code 22. These two codes, which indicate observation level services, are consistent
with one another. The health plan has argued that the enrollee was on inpatient status and that billing with
observation codes is incorrect. The health plan, however, has provided no documentation that the enrollee was
an inpatient: physician order for inpatient level of care, other bills with inpatient place of service code.
Consequently, the health plan has not supported their denial.
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 been met. Therefore, we decided that the Plan has to pay for
observation care discharge day management services provided to the enrollee on July 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on May 14, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on May 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 24, 2019.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation does not support a valid requisition or order for the testing billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on June 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires pulmonary management, rehab therapy, and daily physician visits. The Plan denied your request. The Plan says the enrollee does not have complicated problems that require a medical team.
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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee has been treated for seizures, been ruled out for a stroke, and been treated for aspiration. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 28, 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 a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on May 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vectra DA testing rendered on October 30, 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 services were not medically necessary. The Plan must follow Medicare rules. Medicare rules say that Vectra DA testing is covered when 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of other rheumatoid arthritis with rheumatoid factor of multiple sites. It has not been adequately demonstrated that the Vectra DA test has a functional role when making clinical management decisions in the setting of rheumatoid arthritis. The testing was therefore not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Vectra DA testing rendered on October 30, 2019.