Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe radiation therapy and MRI provided from February 28, 2019 through May 1, 2019.You asked the Plan to waive the cost share forthe radiation therapy and MRI. You say that you were informed the treatment was covered. You say that were not informed about any amounts you would be responsible for.The Plan denied your request. The Plan says the cost share 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 20% coinsurance for each covered radiation therapy service and a$150 copayment for covered diagnostic radiology services in the outpatient department of a network hospital or facility. You have been asked to pay a total of $1,171.12for the radiation therapy and MRI. Date of ServiceServiceAllowed AmountStandard CostMember LiabilityFebruary 28, 2019Radiation Treatment483.3320%96.67March 13, 2019Radiation Therapy Device Insertion1108.18$40$40March 20, 2019Therapeutic Radiology299.2120%59.84March 20, 2019Radiation Treatment598.4220%119.68March 20, 2019MRI358.77$150150April 1, 20193D Radiotherapy$1,108.1820%$221.64April 8, 2019Therapeutic Radiology$115.0720%$23.01April 8, 2019Radiation Port Plan$1,196.8420%$239.37April 8, 2019Radiation Treatment$115.0720%$23.01April 12, 2019Radiation Consult$115.0720%$23.01April 19, 2019Radiation Consult$115.0720%$23.01April 26, 2019Radiation Consult$115.0720%$23.01May 3, 2019Radiation Consult$115.0720%$23.01May 17, 2019Radiation Consult$115.0720%$23.01May 24, 2019Radiation Consult$115.0720%$23.01May 31, 2019Radiation Consult483.3320%96.67TOTAL:$1,171.12Radiation therapy and the MRIfall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.The device insertion falls within "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 cost share forthe radiation therapy and MRI provided from February 28, 2019 through May 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory testing provided on July 9, 2019.You asked the Plan to waive the copayment forlab test. You say that this test has alwaysbeen paid with no responsibility for you in the past, and you believe this test is a preventive service which should be fully covered by the Plan.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $100 copayment for in-network lab testing atan outpatient hospital. This testing was performed due to a non-routine diagnosis, therefore it is considered to be diagnostic lab testing and not a screening or preventive service.You have been asked to pay the allowed amount of $23.44, which is less than the $100 copayment for lab test. lab test 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 costsharing 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 forlaboratory testing provided on July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Novolog injections 100/ml for the enrollee.You asked the Planto pre-approvethe injection. You say that thisis medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveNovolog injections 100/ml for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveUloric tab 40mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication falls under Part D coverage.The Plan must follow Medicare rules.The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveUloric tab 40mg for the enrollee.
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-approveIRF care. You say that the enrollee currently meets IRF admission criteria according to Medicare guidelines.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee is currently stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician 3 times per week or acute rehabilitation nursing care. While the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of need for an intensive rehabilitation therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (76937) provided on July 2, 2019.You asked the Plan to pay for the ultrasound guidance. You say that the enrollee had multiple exams on this date of service please reconsider for processing.The Plan denied your request. The Plan says exact duplicate/claim service.The Plan must follow Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound guidance have not been met.Therefore, we decided that the Plan does not have to pay forultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (76937) provided on July 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 16, 2019 by out of networkprovider. You asked the Plan to pay foroffice visit. You say that you are appealing with additional information.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider isout-of-network with the Plan and prior authorization was not obtained.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 forthe medical services provided on September16, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of aninterlaminar/interspinous process stabilization/distraction device (22869 and 22870).You asked the Plan to pre-approvethe insertion of an interlaminar/interspinous process stabilization/distraction device. You say that this would providesignificant clinical and quality of life benefits to the enrollee.The Plan denied your request. The Plan says studies have not proven the requested service is helpful for the enrollee's condition.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 insertion of an interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in thiscase. Our physician reviewer found the device at issue remains experimental. More research is needed to show safety and efficacy.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 insertion of an interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of an interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia injections for the enrollee.You asked the Plan to pre-approveProlia. You say that the enrollee needs this for the treatment of the enrollee's osteoporosis.The Plan denied your request. The Plan says that the enrollee has not tried and failed Zoledronic acid.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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Zoledronic acid or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found the enrollee's condition does not meet criteria for coverage of Prolia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia injections for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF admission and services for the enrollee. You asked the Plan to pre-approveSNF services. You say that the enrollee needs speech and physical therapy.The Plan denied your request. 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 pre-approve SNF services. Our physician reviewer found that from a nursing perspective, the enrollee has stable vital signs. He has routine Foley catheter care. Regarding rehab services, the enrollee is at total assist with functional mobility, and is non-ambulatory. There are no identifiable skilled therapy service needs. Although there are identifiable skilled nursing service needs, the enrollee does not require skilled nursing or therapy on a dating basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) admission and services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 additional physical therapy home health visits (for a
total of 14 visits).
You asked the Plan to pre-approve additional physical therapy home health visits. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not
medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional physical therapy home health
visits. Our reviewer says that the documentation does not support that the requested services are medically
reasonable or necessary. Our physician reviewer found the enrollee has persistent low back pain and sciatica,
weakness, and edema. The enrollee required stand-by assistance with bed mobility.
The enrollee required modified independence with transfers and walking 150 feet with a rolling walker. The documentation does not support that skilled therapy services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional physical therapy home health visits (for a total of 14 visits).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on June 11, 2019.
You asked the Plan to pay for the domiciliary or rest home visit. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 a domiciliary or rest home visit provided on June 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral digital breast tomosynthesis rendered on August 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
The provider submitted a claim for procedure code 77062 (bilateral digital breast tomosynthesis). This code has
a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have
to pay for the bilateral digital breast tomosynthesis rendered on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on April 1, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 64636 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 64636 is destruction by neurolytic agent, paravertebral
facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint
(List separately in addition to code for primary procedure).
We find that CPT code 64636 is not supported in the medical record. Specifically, the records do not show that
two facet joints underwent RFA; therefore, the code cannot be substantiated. 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 services rendered on April 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diabetic supplies coded as E0607, A4253, A4256, A4258 and A4259 provided on July 19, 2019 and October 7, 2019.You asked the Plan to pay forthe diabetic supplies. You say that that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.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 does not contain a valid delivery ticket and proof of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket submitted.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies coded as E0607, A4253, A4256, A4258 and A4259 provided on July 19, 2019 and October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Januvia for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Januvia for the enrollee.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on June 11, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 92235 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 92235 is fluorescein angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral. We find that CPT code 92235 is not supported in the medical record. Specifically, there is no documentation that images were obtained to support this code. 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 services rendered on June 11, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CT scan provided on July 16, 2019.You asked the Plan to pay forthe CT scan. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are from a work related injury.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third,the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed you, the provider, to send the bill directly to the primary insurer (work related) for payment. As the secondary insurer, the Plan cannot be held responsible for the CT scan until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe CT scan provided on July 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on July 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 20611 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.We find that CPT code 20611 is not supported in the medical record. Specifically, there is no documentation of permanently recorded images to support the billing of this code. 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 forthe surgical servicesrendered on July 31, 2019.