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

We decided that the Plan does not have to pay foranesthesia for diagnostic or therapeutic nerve blocks and injections (01992-P3-AA-QS) provided on April 6, 2019.You asked the Plan to pay foranesthesia. You say that this should be paid.The Plan denied your request. The Plan says modifier P3 is not supported and minor pain procedures under most routine circumstances do not require anesthesia care other than local anesthesia.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for anesthesia. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found minor pain procedures under most routine circumstances do not require anesthesia care other than local anesthesia. Per Medicare criteria, for procedures that do not usually require anesthesia services, monitored anesthesia care could be covered when the patient's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure. The presence of an underlying condition alone, as reported by a diagnosis code, may not be sufficient evidence thatmonitored anesthesia care is necessary. The clinical records provided did not support the P3 (ASA 3) indicator; there was no documentation as to enrollee's condition that warranted neither the P3 modifier nor the overall medical necessity for the need of monitored anesthesia care. The review provided anesthesia was not reasonable and necessary during the procedure at issue. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met.Therefore, we decided that the Plan does not have to pay foranesthesia for diagnostic or therapeutic nerve blocks and injections (01992-P3-AA-QS) provided on April 6, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on May 26, 2018.You asked the Plan to pay for the ambulance services. You say that the claim was timely.The Plan denied your request. The Plan says this claim was untimely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the ambulance services was not filed until June 26, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 26, 2018
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMs system (C2624, 33289).
You asked the Plan to pre-approve a CardioMEMs system. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that this device is considered investigational and non-covered unless in an approved clinical trial. 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 a CardioMEMs system. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not support the enrollee is enrolled in a clinical trial. Without the support of the documentation, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CardioMEMs system have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs system (C2624, 33289).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring in the operating room (95940) provided on August 1, 2019.You asked the Plan to pay for intraoperative monitoring. You say that this was medically necessary.The Plan denied your request. The Plan says there is not documentation that the monitoring physician was in the operating room.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 continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure).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 intraoperative monitoring. Our reviewer says that the documentation does not support the billing of CPT 95940. Our physician reviewer found the professional services at issue were provided from outside of the operating room. Therefore, the billing of any code denoting monitoring from within the operating room 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 intraoperative monitoring have not been met.Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring in the operating room (95940) provided on August 1, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe porcelain crown (D2740) provided on August 26, 2019.You asked the Plan to pay forthe dental service. You say that you previously had this tooth crown on July 22, 2015. You say that you had a severe toothache and infection. You say that you needed a root canal. You also say that this could not have been done without removing and replacing the crown.The Plan denied your request. The Plan says crowns are covered once every 5 years. The Plan also says that the frequency limit has been exceeded.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 and crowns are a covered service, the frequency limit forcrowns has been exceeded.The record shows you last received a crown for tooth # 3 on July 22, 2015 which the Plan paid for. Therefore, we decided that the Plan does not have to pay forthe porcelain crown (D2740) provided on August 26, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee on June 30, 2019.
You asked the Plan to pay for the services. You say that this was denied in error as it was only billed once by the Provider. The Plan denied your request. The Plan says it is inappropriate to submit multiple claims for the professional component (modifier 26) of the same diagnostic test or radiology procedure, as the service is performed once by a single provider.
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 76770 is "Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation." We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the medical records along with supporting documentation of the Check/Remit regarding the claim validates this same service 76770- 26 was paid to the Provider on the same date of service that is being appealed. Therefore, this professional component of service 76770 is not eligible for reimbursement a second time on the same date of service even if the first payment was to another provider. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee on June 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foranesthesia services (CPT 99100) received on October 3, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthis code is not eligible for separate reimbursement.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 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B". Based on the CMS Physician Fee Schedule, this means that the code is not separately reimbursable. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay foranesthesia services (CPT 99100) received on October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 12, 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 July 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Durolane injection for the enrollee.
You asked the Plan to pre-approve Durolane. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Monovisc and Orthovisc (Hyaluronic acid) or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve a Durolane injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for incontinence supplies.You asked the Plan to pay for incontinence supplies. You say that you received a denial notice for the purchased supplies. You say that your primary care doctor requested the supplies for you.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pay for incontinence supplies
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an influenza virus vaccine provided on October 9, 2019.You asked the Plan to pay for the influenza virus vaccine. You say that you have been receiving the flu shot at work for years, which is provided by the county health center in your community. You say that you have never been told you needed a doctor's approval to get the flu shot. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 an influenza virus vaccine provided on October 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 14, 2019 to July 13, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from June 14, 2019 to July 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forSNF care provided to the enrollee from December 2, 2018 through January 9, 2019.You asked the Plan to waive the copayment forSNF care. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 2018 and 2019 EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductiblesand coinsurance). Review of the file show that the enrollee received SNF care provided from December 2, 2018 through December 5, 2018 and January 1, 2019 through January 9, 2019. The enrollee's EOC clearly states, for each admission you pay a $20 copayment per day for days 1-20 of a benefit period, $60 per day for days 21 -44, and $0 per day for days 45-100 of a benefit period. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or a skilled nursing facility. The benefit period ends when you haven't been an inpatient at any hospital or SNF for 60 days in a row. If you go to the hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. 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 forSNF care provided to the enrollee from December 2, 2018 through January 9, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee had a right total knee arthroplasty on 2/25/20. The enrollee states that she has been overworking her left leg and needs someone at her side in case she falls as she does not feel safe to go home with no assistance. The enrollee feels she needs inpatient rehabilitation to get the assist to make progress and take care of herself. She states she is not strong enough and cannot dress and bathe herself and her elderly mother is unable to assist. The enrollee's current level of function is minimal assistance/contact guard assistance for supine to sit, sit to stand, and transfers. The enrollee needs minimal assistance/contact guard assistance with bed mobility and toilet transfers. In regards to ambulation, the enrollee needed contact guard assistance x 12 feet and 60 feet with visual cues on 2/25/20. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee had significant post-operative complications or that her medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy and occupational therapy but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings, panoramic x-ray, prophylaxis, oral hygiene instructions, and screening provided on September 24, 2019.You asked the Plan to pay forthe bitewings, panoramic x-ray, prophylaxis, oral hygiene instructions, and screening. You say that prior to switching to this insurance, you were promised you would get better dental coverage than what you had. You also say that you innocently assumed these services would be covered.The Plan denied your request. The Plan says these services are not covered under your 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 forthe bitewings, panoramic x-ray, prophylaxis, oral hygiene instructions, and screening provided on September 24, 2019.Your complaint about being misled by the Planis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar sacral orthosis provided on October 29, 2019.You asked the Plan to pay forthelumbar sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rulesfor telehealth services were not 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 forthe lumbar sacral orthosis provided on October 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe fine needle aspiration biopsy provided on October 8, 2019.You asked the Plan to waive the copayment forthe fine needle aspiration biopsy. You say that the cost is a hardship. You say that your share should be adjusted.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 $225 copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay a $225 copayment for the fine needle aspiration biopsy. The fine needle aspiration biopsy falls within the "Outpatient Surgery, including services provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The records show that the fine needle aspiration biopsy was performed. 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 forthe fine needle aspiration biopsy provided on October 8, 2019.