Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the urology supplies provided on December 9, 2019.
You asked the Plan to pay for the urology supplies. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says when DME is furnished for use in a SNF during a covered Part A stay the
payment is already included in the payment the SNF receives for the covered stay.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. The rules
say that Medicare does not pay any provider or supplier other than the facility or hospital for supplies furnished
to a beneficiary.
In this case you asked the health plan to pay for medical supplies provided to the enrollee in a SNF setting.
Records show that the urology supplies were used in a SNF. The facility must furnish all necessary covered
supplies to the beneficiary either directly or under arrangements made with outside providers. Theses supplies
would have been included in the global payment submitted to the plan by the facility. If the health plan is not
covering the SNF stay, the cost of these supplies is absorbed by the facility. Payment for this claim must be
submitted to the facility for payment, not the health plan. Therefore, we decided that the Plan does not have to
pay for the urology supplies provided on December 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc syringes to be provided by a specialty pharmacy.
You asked the Plan to pre-approve the Synvisc syringes. You say that the enrollee needs this treatment. The Plan denied your request. The Plan says this is being picked up from a specialty pharmacy so it cannot be covered by Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Synvisc syringes to be provided by a specialty pharmacy.
Benefits for the Synvisc syringes 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 18, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain. The requested Vertiflex spacer is considered experimental in nature, as more research is needed to show efficacy. The services are therefore not reasonable or 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-approve a Vertiflex spacer.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pay for the SNF services provided October 31 to November 2, 2019. We
decided that the Plan does not have to pay for the remaining dates of service .
You asked the Plan to pay for the SNF services. You say that services were medically necessary. The Plan says
that services provided October 10 to October 30, 2019 and services provided November 3 to November 8, 2019
do not meet coverage criteria. We decided that the Plan has to pay for the SNF services provided October 31 to November 2, 2019.
Services required a level of complexity that made a SNF setting appropriate.
We also decided that the Plan does not have to pay for services provided October 10 to October 30, 2019
and services provided November 3 to November 8, 2019. The level of complexity did not require SNF level
care. There was no daily skilled care need.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve DUROLANE knee injections (J7318x2).
You asked the Plan to pre-approve the injections. You say that you would like reconsideration as this drug is medically necessary. The Plan denied your request. The Plan says that the member does not meet coverage criteria for this service.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 injections. Our reviewer says that the documentation supports that DUROLANE is medically reasonable and necessary for the member. Our physician reviewer found the documentation supports that the DUROLANE is safe and effective for this member. 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 injections have been met. Therefore, we decided that the Plan has to pre-approve DUROLANE knee injections (J7318x2).
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: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to adjust the coinsurance for the knee orthosis (L1833). We decided that the Plan does not have to waive the coinsurance for the knee orthosis.
You asked the Plan to waive the coinsurance for the knee orthosis (L1833). You say that you did not use the brace. The Plan says that you were charged the coinsurance correctly.
We decided that the Plan has to adjust the coinsurance for the knee orthosis (L1833).
We also decided that the Plan does not have to waive the coinsurance for the knee orthosis.
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 the knee orthosis (L1833). Therefore, we decided that the Plan has to adjust the coinsurance for the knee orthosis to 20% of the total cost $551.74.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on December 12, 2019.
You asked the Plan to pay for the PCD. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the health plan. This item is used for a preventative service and is excluded from Medicare coverage. Your request is not medically necessary because the records show that the service was requested to prevent blood clots after your knee replacement surgery. Therefore, we decided that the Plan does not have to pay for a PCD (E0676) provided to the enrollee on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on May 28, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
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 drug testing rendered on May 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 8, 2019 by a non-network
provider.
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 by a non-network provider without prior authorization.
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 medical services provided on May 8, 2019 by
a non-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on August 2, 2018. You asked the Plan to waive the coinsurance for an injection. You say that it has been so long that the Plan should just eat the cost of this. The Plan denied your request. The Plan says the correct coinsurance has been applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed
amount is $38. The total amount you are being asked to pay is $7.60 ($38 x 20% = $7.60). The correct coinsurance has been applied to the services provided. An injection falls within the Medicare Part B prescription drugs/in-network 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 an injection provided by a participating provider on August 2, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS)
device.
You asked the Plan to pre-approve the TENS unit. You say that the TENS unit has helped you in the past. The
Plan denied your request. The Plan says the guidelines for approval have not been met.
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 the TENS unit. Our reviewer says that a
TENS unit is not considered medically reasonable and necessary in this case. Our physician reviewer found,
according to the narrative documentation, the TENS unit was ordered to treat neck pain. This is not a condition
for which TENS therapy is covered. While the enrollee is noted to have a history of scoliosis, the nature and
location of the scoliosis is not noted. While the enrollee is noted to have had multiple back surgeries, the nature
and location of the surgeries is not noted. While the request notes a diagnosis of spondylosis, there is no
evidence that the enrollee has myelopathy or radiculopathy. The documentation is insufficient to support that
the requested TENS unit is medically necessary and reasonable.
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 TENS unit have not been met. Therefore, we decided that the Plan does not
have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the allergen immunotherapy services provided from December 2, 2019 to December 27, 2019.You asked the Plan to waive the coinsurance for the allergen immunotherapy services. You say that you have previously paid $1.99 for your allergy injections. You say you should not be charged $2.54 for the allergy injections. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay $0 copayment for the administration of an in-network Medicare-covered Part B drug.The Plan says you must pay $2.54 for each of the allergen immunotherapy services. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for each of the allergen immunotherapy services. The record shows you were charged with code 95117, which is considered a professional service for allergen immunotherapy. Therefore, we decided that the Plan has to waive the coinsurance forthe allergen immunotherapy services provided from December 2, 2019 to December 27, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on January 22, 2019. You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not separately payable. 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 99190 is assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour. We find that CPT code 99190 is not supported in the medical record. Specifically, the enrollee was inpatient for this date of service. Therefore, payment for this service would be included in the Part A DRG payment to the facility. Based on this information, we decided that Medicare rules for coverage of the assembly and operation of pump with oxygenator or heat exchanger services have not been met. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger services coded 99190 provided on January 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 29, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you went for the test but no surgery followed. You say that you should be refunded. 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). Your contract with the Plan clearly says that you must pay a $15 copayment for provider and professional services at an in-network specialist's office. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services and eyeglasses on January 7, 2020 purchased from both out-of-network providers.
You asked the Plan to pay for the services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says you do not have out-of-network benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The providers are not in-network and your EOC clearly states, you must use the supplemental vision plans "select" network participating providers. Therefore, we decided that the Plan does not have to pay for vision services and eyeglasses on January 7, 2020 purchased from both out-of-network providers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out of network (OON) provider.You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the medical services provided on January 7, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for aminophyllin injections (J0280x3) provided on October 29, 2019.
You asked the Plan to pay for the aminophyllin injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation did not support the units 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 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 aminophyllin injections. Our reviewer says that CPT code J0280x3 does not meet criteria for billing or reimbursement consideration. Our physician reviewer found the total amount of aminophylline injected was 75mg. This amount is covered by a single unit of the billed code. Billing three units of the code is not supported. 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 aminophyllin injections have not been met. Therefore, we decided that the Plan does not have to pay for aminophyllin injections (J0280x3) provided on October 29, 2019.