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

We decided that the Plan does not have to pay forthe perfusionist services provided to "the beneficiary" on September 4, 2019.You asked the Plan to pay forthe services provided. You say that the charges are for the perfusionist that set up and operated the heart-lung machine.The Plan denied your request. The Plan says payment for this service would be included in the payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary.We looked at the file and Medicare rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This service was provided via arrangement of the facility. Payment for this service would have been included under the facility claim.Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay forthe perfusionist services provided to "the beneficiary" on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cimzia (J0717).
You asked the Plan to pre-approve Cimzia. You say that the requested medication is necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has
not been met.
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 Cimzia. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the reviewed medical records outline a
diagnosis and treatment plan for non-axial spondyloarthropathy. This diagnosis is not supported by Medicare
approved compendia. Without this support, 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 Cimzia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Cimzia (J0717).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF care is medically necessary.The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.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 requestto pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found 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's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit from and participate in additional physical and occupational therapy, but 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 16, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the service 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 physician's services provided on August 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 12, 2019.You asked the Plan to pay forlaboratory test. You say that the referring physician determined that this test was medically necessary.The Plan denied your request. The Plansays the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is nota 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 forthe medical services provided on August 12, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe observation stay, the CT scans, or the nuclear medicine scan provided from July 24, 2019 to July 26, 2019.You asked the Plan to waive the copayments forthe observation stay, the CT scans, and the nuclear medicine scan. You say that these charges are absurd and you should not be billed for the charges.The Plan denied your request. The Plan says you have been charged the correct costsharing 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 $175 copayment foreach Medicare-covered outpatient hospital observation stay at a hospital facility and a $200 copayment for each type of Medicare-covered diagnostic radiology service including MRI, CT scan, Nuclear scans, and PET scans, per date of service. You have been asked to pay a total cost-share amount of $674.87. The observation stay falls within the "Outpatient hospital services" benefit category. The CT scans and the nuclear medicine scan fall within the "Outpatient diagnostic tests and therapeutic services andsupplies" benefit category
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by "the provider" on July 19, 2019.You asked the Plan to pay forthe ambulance services. You say that there was no way you could have driven a car to the hospital and after treatment you didn't have to go.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 19, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by "the provider" on July 19, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for a tissue exam (88307) provided on July 2, 2019.You asked the Plan to pay for the tissue exam. You say that you would like reconsideration as the place of service should not be a factor. The Plan denied your request. The Plan says that physicians may not bill or be separately paid for the technical and/or professional components of laboratory services performed in a facility setting.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 88307 is supported in the medical record. Specifically, the provider billed for the Professional Component of 88307 (88307-26). 88307 has a Pro/Tech Flag on 1 per the Physician Fee Schedule. This means that this code is a diagnostic test that has both a professional and technical component. Modifier 26 and TC can be used with these codes and the Professional Component is separately payable in this case. Based on this information, we decided that Medicare rules for coverage of the tissue exam have been met. Therefore, we decided that the Plan has to pay for a tissue exam (88307) provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided to the enrollee on August 13, 2019 by the out-of-network provider.
You asked the Plan to pay for the out-of-network services. The Plan denied your request. The Plan says there is no network deficiency for the services and alternate network providers were found.
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 out-of-network services. Therefore, we decided that the Plan does not have to pay for the podiatry services provided to the enrollee on August 13, 2019 by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 29, 2019 to October 17, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 29, 2019 to October 17, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided from February 25, 2019 to April 3, 2019, by "the doctor". You asked the Plan to pay forthe services provided. The Plandenied your request. The Plan says theservices are non-covered as the provider has opted out of Medicare.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider at issue has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided from February 25, 2019 to April 3, 2019, by "the doctor"
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 10, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you cannot afford the cost share.The Plan denied your request. The Plan says that the claim processed 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 $300 copayment for each covered, one-way ambulance trip by ground or water. You have been asked to pay $300 copaymen tfor the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water 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 ambulance transport provided on August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on August 26, 2019.You asked the Plan to waive the copayment foran EGD. You say that you feel that the $600 charge for a short procedure is too much.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 $600 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on August 26, 2019. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $600 copayment. You have been asked to pay a $600 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 foran EGD provided on August 26, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH care is medically necessary for the enrollee's recovery and he meets the criteria for coverage.The Plan denied your request. The Plan says the records do not show that it is medically necessary for the enrollee to be in an LTACH inplace of an acute care hospital.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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for shortness of breath related to congestive heart failure (CHF) and pulmonary hypertension. The enrollee is notintubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for(CPT Code 99213) and (CPT Code 92250) provided to the enrollee on August 19, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the member was enrolled in hospice at the time of services. The Plan states per Medicare guidelines, the member's services should be billed under Original Medicare.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 enrolleewas under the Medicare hospice benefit for the dates of service at issue in this appeal. The enrollee was enrolled in hospice from June 29, 2019 through September 25, 2019.Therefore, we decided that the Plan doesnot have to pay for(CPT Code 99213) and (CPT Code 92250) provided to the enrollee on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood pressure cuff purchased on February 1, 2019.You asked the Plan to pay forthe blood pressure cuff. You say that you have been diagnosed with high blood pressure and is on medication so this device is medically necessary.The Plan denied your request. The Plan says the plan cannot pay a provider who is not eligible to participate in Medicare.The Plan must follow Medicare rules. Medicare rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.  You can find this rule at Program Integrity Manual, Ch. 15 15.1. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the blood pressure cuff have not been met.Therefore, we decided that the Plan does not have to pay for blood pressure cuff purchased on February 1, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSupartz for "the beneficiary" .You asked the Plan to pre-approveSupartz. The Plan denied your request. The Plan says the enrollee has not had previous treatment, a contraindication, or intolerance to Orthovisc and Monovisc.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 Supartz. Our physician reviewer found that the enrollee has a diagnosis of primary osteoarthritis of the right and left knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs.  The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrollee 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 Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approveSupartz for "the beneficiary".
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral lower extremity runoff (75635).You asked the Plan to pre-approvea CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff. Our reviewer says that the service is medically necessary. Our physician reviewer found the enrollee is noted to have symptoms of claudication. Ultrasound (US) imaging has identified a decreased ankle brachial index (ABI). The provider has noted that he is clinically suspicious of an inflow lesion. Therefore, imaging to look for an inflow lesion is warranted. The requested CT scan 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 a CTA of the abdominal aorta and bilateral iliofemoral lower extremity runoff have been met.Therefore, we decided that the Plan has to pre-approvea computed tomographic angiography (CTA) of the abdominal aorta and bilateral iliofemoral lower extremity runoff (75635).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 30, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on August 30, 2019.