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

We decided that the Plan does not have to pay for physician services provided on July 12, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysicianservices. You say that you have been going to this doctor for 25 years.The Plan denied your request. The Plan says the provider is not in-network.Medicare rules say that plans can require enrollees to get care from network providers. The contractwith 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 forphysician services provided on July 12, 2019 by an out of network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport (A0428) provided
August 21, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the facility told you there
would be no charge for the ambulance transport. The Plan denied your request. The Plan says the evidence of
coverage explains the copayment for ambulance services.
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 Ground Ambulance Services.
You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls
within the Ground Ambulance Services 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 ambulance transport (A0428) provided August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee is receiving appropriate inpatient acute care and does not require transfer to LTACH.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 there is a need for a higher level of care than an outpatient facility. There will be a slow wean, expected to last over a 25-dayhospitalization. There are challenges with feeding, bleeding, and coagulopathy, needing intermittent transfusions.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 been met.Therefore, we decided that the Planhas to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.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 waive the copayment for the comprehensive evaluation provided on July 30, 2019.
You asked the Plan to waive the copayment for the comprehensive evaluation. You say that this was your annual wellness visit with your gynecologist. You say that the bill is a burden. 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 $30 office visit copayment if services are provided by a specialist.
You have been asked to pay a $30 copayment for the comprehensive evaluation. The comprehensive evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the provider is a gynecologist. 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 comprehensive evaluation provided on July 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevitamins and unspecified equipment.You asked the Plan to pre-approvethe requested services. You say that if the enrollee stops taking medication, she can end up with low sodium.The Plan denied your request. The Plan says the requested drug is not covered under the enrollee's medical plan.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-approvevitamins and unspecified equipment.Benefits for the requested servicesmay be available under Medicare Part D.Contactthe 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 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 nonemergent,
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formoderate sedation services (99153) provided on July 1, 2019.You asked the Plan to pay for the moderate sedation services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment forthis service is included in payment to the facility.The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Specifically, CPT code 99153 is a technical component code. Payment for this service is included in the payment to the facility and is not separately reimbursable. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) provided on July 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not have to waive the copayments forintravenous infusions provided from October 14, 2019 to November 4, 2019.You asked the Plan to waive the copayments forintravenous infusions. You say that you received infusions, not surgical procedures.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 sharinginformation (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgicalcenters. You received intravenous infusions at an outpatient hospital facility from October 14, 2019 to November 4, 2019 for a total of 4 visits. Therefore, you are responsible to pay the allowed amount of $226.99 for each service. The total amount you owe is: $226.99 (copayment) x 4 (outpatient hospital services) = $907.96. You have been asked to pay the total copayment amount of $907.96 for intravenous infusions. Intravenous infusions fall within the outpatient surgery and other medical 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 copayments forintravenous infusions provided from October 14, 2019 to November 4, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One injections.You asked the Plan to pre-approvethe Synvisc-One injections. You say that the enrollee has arthritis and this treatment is medically necessary.The Plan denied your request. The Plan says viscosupplementation may be considered necessary; however, the plan's preferred agents would not likely be less effective.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 the Synvisc-One injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy requirements. Our physician reviewer found the enrollee has diagnoses of pain in the right and left knees due to primary osteoarthritis. There is no documentation that Orthovisc and Monovisc have been tried and failed. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/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 the Synvisc-One injections have not been met.Therefore, we decided that the Plan does not have to pre-approveSynvisc-One injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90792) provided on August 13, 2019.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were in-network providers who could render the services at issue. The services were not emergent or preauthorized.
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 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 the outpatient mental health services (90792) provided on August 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a hip x-ray (73502) provided on September 15, 2019.
You asked the Plan to pay for the hip x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says it is not appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the claim line does not match the diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 73502 LT is not supported in the record. Specifically this claim was billed with diagnosis code S72.011; unspecified intracapsular fracture of right femur, initial encounter for closed fracture. Modifier LT does not match the diagnosis code. Based on this information, we decided that Medicare rules for coverage of the hip x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a hip x-ray (73502) provided on September 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 72 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve 72 additional routine transportation trips. You say that you need the additional routine transportation trips. The Plan denied your request. The Plan says the requested services exceed the benefit allowance. Therefore, coverage criteria has not been met. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 36 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 72 additional routine transportation trips (A0120).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 3, 2019 by an out of network (OON) provider.You asked the Plan to pay for genetic testing. You say that you are the only lab that can provide this testing.The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 forgenetic testing provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Heparin Sodium for the enrollee.
You asked the Plan to pre-approve Heparin Sodium. The Plan denied your request. The Plan says Original
Medicare is responsible for coverage for the routine costs associated with clinical trials.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve Heparin Sodium as part of a clinical trial. The Plan does not
cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have
to pre-approve Heparin Sodium for H. the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of x-rays showing joint space narrowing, subchrondral sclerosis, osteophytes, and sub-chondral cysts. 
 
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no detailed physical examination of the affected joints, imaging studies supporting a diagnosis of osteoarthritis, or detailed trialed nonpharmacologics or conservative therapies. 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc injection for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on March 27, 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 claim was not billed correctly. The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on March 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed,
however, 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. We find that payment for the lab services are not supported in the
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in
regards to the physician's intent that the tests be performed prior to services taking place. Therefore, we
decided that the Plan does not have to pay for the laboratory services provided on July 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.
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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was treated for abdominal pain and a large duodenal ulcer. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the acute hospital. The enrollee was at an independent to stand by assist/contact guard assist level for functional mobility including gait to 500 feet with no device. The enrollee was independent with the activities of daily living. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. There are no identifiable skilled therapy service needs. Skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the you do not require the necessary services on an inpatient basis in a skilled nursing facility setting. You do not meet severity of illness or intensity of service criteria on 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 5, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you had your yearly physical and should not be charged as an office visit. The Plan denied your request. The Plan says 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for each primary care doctor visit for Medicare-covered benefits. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/ Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a follow-up visit for right arm numbness, edema, and vitamin D insufficiency. 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 on September 5, 2019.