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

We decided that the Plan does not have to waive the copayment for non-emergency ambulance transport (A0428) provided on June 27, 2019
You asked the Plan to waive the copayment for non-emergency ambulance transport. You say that the transportation by ambulance was necessary since you were unable to bend your knee to fit into a car. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed 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 $200 copayment for ambulance services. You have been asked to pay $200 for non-emergency ambulance transport. 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 non-emergency ambulance transport (A0428) provided on June 27, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on June 21, 2019 to July 23,
2019 by the out of network provider.
You asked the Plan to pay for home health services. You say that you are still trying to become in-network with
the Plan. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for home health services provided on June 21, 2019 to
July 23, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 22, 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 codes 22552 and 22853 are 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 22552 is arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure). The definition of code 22853 is insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). We find that CPT codes 22552 and 22853 are not supported in the medical record. Specifically, the operative report does not contain documentation of an arthrodesis using an anterior interbody approach to support code 22552 or insertion of an interbody biomechanical device for code 22853. 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 surgical services rendered on August 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on September 11, 2019.
You asked the Plan to waive the copayment for an outpatient surgery. You say that the Enrollee says she was not aware that the procedure would cost this much. The Plan denied your request. The Plan says the correct copayment has been applied to the service that was provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Enrollee's contract with the Plan clearly says that enrollees must pay a $400 copayment for outpatient surgery/the Plan/outpatient hospital facility. The Enrollee has been asked to pay a $400 copayment for an outpatient surgery. The correct copayment has been applied to the surgery that was provided. An outpatient surgery falls within the outpatient surgery/the Plan/outpatient hospital facility benefit category. 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 for an outpatient surgery provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on May 30, 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 Medicare has established limited coverage of diagnosis codes that support medical necessity for procedure code 51784.
The provider submitted a claim for procedure code 51784 with diagnosis code M48.062 (spinal stenosis, lumbar region with neurogenic claudication). This diagnosis code is not listed as supporting medical necessity in the Medicare rules. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 95955, 95910, and 51785. Codes 95955 and 95910 are column II codes with a modifier indicator of 1 when billed with column I code 51785. Codes 95955 and 95910 were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on May 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for debridement (11042) provided on October 10, 2019.
You asked the Plan to pay for the debridement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment for CPT code 11042 is included in the allowance for another service that has already been adjudicated.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder 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 debridement. Our reviewer says that CPT code 11042 59 meets criteria for billing or reimbursement consideration. Our reviewer found CPT 11042 has a bundled relationship with CPT 11043, however an appropriate modifier is allowed to unbundle the two codes providing the medical records validated the use of the modifier. CPT 11042 billed with an appended 59 modifier was appropriately billed. The medical records validate that 11042 was performed on a separate wound on the opposite side of the body from where procedure 11043 was performed. 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 debridement have been met. Therefore, we decided that the Plan has to pay for debridement (11042) provided on October 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit for the evaluation and management of an established patient (99349) provided on June 21, 2019 to July 23, 2019 by the out of network provider.
You asked the Plan to pay for a home visit for the evaluation and management of an established patient. You say that you have begun the process to be in-network with the Plan. You also say that a loss of all of these prior dates of service will cause an immediate shut down of your practice and these patients will be forced to rely on ambulance trips to the emergency room for even the most routine of care. The Plan denied your request. The Plan says the group is a non-network provider who does not work with the member's health plan, and the member was referred by a physician, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health 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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a home visit for the evaluation and management of an established patient (99349) provided on June 21, 2019 to July 23, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on July 9, 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 codes 37229-53-RT, 37233-53 and 35302-RT are 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 37229 is revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed. The definition of code 37233 is revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure). The definition of code 35302 is thromboendarterectomy, including patch graft, if performed; superficial femoral artery. We find that CPT codes 37229, 37233, and 35302 are not supported in the medical record. Specifically, the records do not include documentation of an open or percutaneous endovascular revascularization to support code 37229, documentation of unilateral open or percutaneous endovascular revascularization of the tibial/peroneal artery to support code 37233, or documentation of treatment of occlusive disease of unilateral tibial or peroneal arteries by endovascular revascularization to support code 37233. 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 to the enrollee on July 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
You asked the Plan to pre-approve the Durolane. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the plan's medical necessity guidelines for coverage of the requested drug.
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 Durolane. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has diagnosis of unilateral primary osteoarthritis of the right and left knees. There is no documentation that the enrollee has had a trial of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or have an adverse effect 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a preventive medicine service (99397) provided on November 8, 2019.
You asked the Plan to pay for the preventive service. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says that preventative medicine services should only
be performed once per calendar year and this service has been billed more than once per calendar year.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
the Plan follows these rules.
You were referred for the preventive service by a doctor. The doctor is a contract
provider. The file does not show that the Plan provided notice that the preventive service would not be
covered. Under Medicare rules, this means the preventive service is considered approved by the Plan.
Therefore, we decided that the Plan has to pay for a preventive medicine service (99397) provided on
November 8, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthoses provided on December 18, 2018. 
 
You asked the Plan to pay for the ankle foot orthoses (L1971). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the elapsed time is less than the 5-year reasonable useful lifetime period. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 
 
The file shows that the enrollee had ankle foot orthoses (L1971) provided on November 2, 2016 at the time the ankle foot orthoses (L1971) was received from you. The orthoses provided on November 2, 2016 serves the same purpose as the ankle foot orthoses (L1971) at issue. The orthoses are still within the 5-year RUL and the documentation submitted does not show that the orthoses are irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the ankle foot orthoses at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met. Therefore, we decided that the Plan does not have to pay for the ankle foot orthoses provided by on December 18, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion with an out-of-network Ophthalmologist.
You asked the Plan to pre-approve the services. You say that you do not believe doctors can diagnose your problem and are requesting for a referral outside The Plan denied your request. The Plan says they will not refer you to a non-Plan ophthalmologist because the services are available in Plan and you are contractually required to obtain this service from network providers.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion with an out-of-network Ophthalmologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle.
You asked the Plan to pre-approve a Group 1 standard power operated vehicle. You say that you are disabled and need a scooter. The Plan denied your request. The Plan says your home is not POV accessible to the locations of MRADL's.  The Plan follows Medicare rules. Medicare rules say that the enrollee's home must provide adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. The Mobility Assessment shows that your home cannot accommodate a scooter to help you with your MRADL's. This means that Medicare rules for coverage of a Power Mobility Device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on July 24, 2019 by out of
network provider.
You asked the Plan to pay for home health services. You say that your company is still trying to become in-network
with the Plan. You say that without your services, members would be forced to rely on ambulance trip to
the ER for routine care. The Plan denied your request. The Plan says no prior authorization was 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 for home health services provided on July 24, 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 lumbar sacral orthosis provided to the enrollee on November 20, 2019.
You asked the Plan to pay for the orthosis. The Plan denied your request. The Plan says that the billed supply code cannot be verified.
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 the orthosis. Our reviewer says that the orthosis was not considered medically reasonable and necessary in this case. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar sacral orthosis have been met. The documentation does not support that the lumbar sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a physical examination of the back. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a lumbar sacral orthosis. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar sacral orthosis provided to the enrollee on November 20, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the BiPAP and the Monitoring feature/device provided by on October 27, 2019.
You asked the Plan to pay for the BiPAP (E0471) and the Monitoring feature/device (A9279). You say that you don't understand why the BiPAP would be granted and the supplies are denied. The Plan denied your request. The Plan says that the monitor is not covered by Medicare and the BiPAP was not authorized.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the BiPAP (E0471) and the Monitoring feature/device (A9279). The doctor is a contract provider. The file does not show that the Plan provided notice that the BiPAP (E0471) and the Monitoring feature/device (A9279) would not be covered. Under Medicare rules, this means the BiPAP (E0471) and the Monitoring feature/device (A9279) is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the BiPAP and the Monitoring feature/device provided on October 27, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on June 21, 2019 to August 16, 2019 by the out of network provider.
You asked the Plan to pay for home health services. You say that the facility unexpectedly closed their doors. You say that the facility took in these patients. You say that you have been trying to become in-network with the Plan. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for home health services provided on June 21, 2019 to August 16, 2019 by the out of network provider.