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

We decided that the Plan does not have to pay for podiatry services provided by an out of network (OON) provider.

You asked the Plan to pay for podiatry services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained by the provider or the nursing facility.

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 podiatry services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Intravenous infusion, for therapy, prophylaxis, or diagnosis
(specify substance or drug) (96366) provided March 9, 2020
You asked the Plan to pay for the infusion services. You say that please review and reprocess for payment. Per
your coder, all codes are supported and should be paid. The Plan denied your request. The Plan says the records
do not support the service 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 code 96366 is intravenous infusion, for therapy, prophylaxis or
diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary
procedure).
We find that CPT code 96366 is not supported in the medical record. Specifically, this CPT code is an add-on
type code that requires a primary code. This code cannot be separately reimbursed. The records also do not
support that intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each
additional hour (List separately in addition to code for primary procedure) was performed. The plan had made
multiple attempts to obtain the needed records without success. Based on this information, we decided that
Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that the Plan
does not have to pay for Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)
(96366) provided March 9, 2020
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp (J0881).
You asked the Plan to pre-approve Aranesp. You say that this is the treatment of choice to prevent the need for
blood transfusions. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Aranesp. Our reviewer says that the
criteria for coverage of Aranesp has not been met. Our physician reviewer found the Plan requires a trial of
drug Retacrit before they will approve the requested drug, Aranesp. Based on the medical records provided, the
patient has not tried and failed the required drug. There is no indication that the plan's required drug would
likely be less effective or have adverse effects for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aranesp (J0881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevation system and transit option.
You asked the Plan to pre-approve a seat elevation system and transit option. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not
covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered.
We looked at the file and Medicare rules. The power seat elevation system is non-covered. The requested
transit option is being required as a component of the requested seat elevation system. Therefore, any
components being requested for use with the seat elevator are also non-covered. Based on this information, we
decided that Medicare rules for coverage of a seat elevation system and transit option have not been met.
Therefore, we decided that the Plan does not have to pre-approve a seat elevation system and transit option.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora breast ultrasound provided on June 22, 2020.You asked the Plan to waive the copayment fora breast ultrasound. You say that you should not be charged for a mammogram.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 $0 copayment for diagnostic mammograms and a $110 copayment for ultrasounds. You have been asked to pay a $110 copayment for a breast ultrasound. A breast ultrasound 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 fora breast ultrasound provided on June 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveNeulastaand Cabazitaxel (J2505, J9043).You asked the Plan to pre-approveNeulasta and Cabazitaxel. You say that the drugs requested are medically necessary to treat the enrollee's condition.The Plan denied your request. The Plan says since the enrolleeis currently enrolled in a Medicare-approved clinical trial, Original Medicare pays directly for the care associated.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve Neulasta and Cabazitaxel as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approveNeulasta and Cabazitaxel (J2505, J9043).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on April 17, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed with an inappropriate diagnosis code.
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 99284 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. 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 emergency department visit. Our reviewer says that the documentation does not support that the services were billed correctly. Our coding reviewer found the enrollee received emergency department visit coded 99284. This code was billed with a primary diagnosis of T36.8X5A (Adverse effect of other systemic antibiotics, initial encounter - Billable). The hematuria as the adverse effect of the medication is sequenced as a first listed diagnosis. The secondary diagnosis code for adverse effect of Coumadin indicates this was taken as prescribed and is not considered a poisoning. The code for atrial fibrillation is coded and reported as it was the reason for the Coumadin intake. Billing the Adverse Effect first or alone would be inappropriate.
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 emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99284 provided on April 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair (PWC).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC is covered when specific criteria are met.We asked our physicianreviewer 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 these services. Our reviewer says that the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has a diagnosis of multiple sclerosis and a personal mobility deficit that impairs participation in mobility-related activities of daily living (MRADLs) in the home. The durable medical equipment evaluation states he would be safest within the home using a walker or manual wheelchair. The documentation indicates he has a visual impairment that would not support that he can safely maneuver a PWC. The PWC is also being requested for use outside of the home. The services do not meet the criteria for coverage and are 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 pre-approvea Group 3 power wheelchair (PWC).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness exam you had on July 27, 2020.
You asked the Plan to pay for the exam. The Plan denied your request. The Plan says this is only covered once
per year.
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 $0
copayment for an annual wellness visit once every 12 months.
Review of the file shows that you had an annual wellness exam on July 27, 2020. The records also show that
you had a covered annual wellness exam on January 20, 2020. This type of exam is only covered once every 12
months. The requested exam exceeds the benefit limit. This means that you have been asked to pay the correct
amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the
annual wellness exam you had on July 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) services provided on August 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you should not be responsible for this bill. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered 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 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 the office visit (99213) services provided on August 17, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentlab services you received at an outpatient hospital facility on June 20, 2020.You asked the Plan to waive the copaymentthe lab services. You say that the Plan has waived your copayments for labs in the past.The Plan denied your request. The Plan says it waived copayments in the past as a courtesy to you.  The Plan says that you were assessed this copayment correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for lab services received at an outpatient hospital facility. You have been asked to pay a $40 copayment for the lab services. The Plan is under no obligation to waive this amount as a courtesy, even if they have done so in the past. 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 copaymentlab services youreceived at an outpatient hospital facility on June 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

e decided that the Plan does not have to pay forthe ultrasound services (76882) provided on April 15, 2020.You asked the Plan to pay forCPT code 76882. 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 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. In this case, we have confirmed that code 76882 has a bundled relationship with code 93971 and cannot be paid as billed. This code cannot be paid as a separate line item unless an appropriate modifier is billed to represent the service as being separate and distinct. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay forthe ultrasound services (76882) provided on April 15, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided from October 9, 2019 to October 21, 2019.You asked the Plan to pay foracute inpatient hospital care. You say that the inpatient level of care from 10/9/19 to 10/21/19 was medically necessary.The Plandenied your request. The Plan says that the inpatient level of care from 10/9/19 to 10/21/19 was not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the inpatient level of care from 10/9/19 to 10/21/19 was medically necessary. Our physician reviewer found the review indicates that the enrollee was admitted to Med ICU on 10/9/19 for hypotension following an exchange of her tunneled dialysis line. She was admitted from LTACH. Member required low dose Levophed and Neosynephrine, successfully transitioned off Levophed 10/17/19. She required ventilator for a short time 10/10/19, transitioned back to trach collar, then placed back on the vent 10/11/19 to 10/13/19, went back to trach collar only to be ventilated again off and on till fully transitioning to trach collar 10/16 (with short times of ventilator through the rest of her stay). Ultimately discharged back to LTACH on 10/21/19.The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from October 9, 2019 to October 21, 2019.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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the comprehensive oral evaluation 
(D0150), the prophylaxis (D1110), the initial periapical x-ray (D0220), and 7 additional periapical x-rays 
(D0230) provided on September 19, 2019. 
 
You asked the Plan to pay the in network rate for the dental services. You say that you called dentists on the 
plan's list of providers and none of them accepted your insurance. You say that you were advised by a plan 
representative to go to the nearest dentist that accepts your insurance. The Plan denied your request. The Plan 
says the provider in this case is not a network provider. The Plan says that dental services that you receive out 
of network are not covered. 
 
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 when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay the in network rate for the comprehensive oral evaluation (D0150), the prophylaxis 
(D1110), the initial periapical x-ray (D0220), and 7 additional periapical x-rays (D0230) provided on 
September 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician certification provided on September 4, 2019.
You asked the Plan to pay for the physician certification. You say that the corrected claim had a GW modifier.
You say that the services are not related to hospice and should be reconsidered. The Plan denied your request.
The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the physician certification provided on September 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for 3 extractions (D7210), the 3 endosteal implants
(D6010), the interim partial denture (D5820), the guided tissue regeneration, resorbable barrier (D4266), and
the sinus augmentation (D7951) provided on November 15, 2019.
You asked the Plan to reimburse you for the dental services. You say that you paid 100% of the cost and not
the 80% that the Evidence of Coverage says you should pay. You also say you should be reimbursed 20% of
what you paid for the services you received. The Plan denied your request. The Plan says the provider in this
case is not a participating plan provider. The Plan also says you must use a participating provider for the
services to be covered.
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, services provided out of network are
not covered. The record shows that you were not referred for the services. Therefore, we decided that the Plan
does not have to reimburse you for 3 extractions (D7210), the 3 endosteal implants (D6010), the interim partial
denture (D5820), the guided tissue regeneration, resorbable barrier (D4266), and the sinus augmentation
(D7951) provided on November 15, 2019.