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

We decided that the Plan does not have to pay forthe services (CPT 99152) provided on June 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed service cannot be verified.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 99152 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older".We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 99152 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation to validate that an independent trained observer was present to assist in the monitoring of the patient's level of consciousness and physiological status for the initial 15 minutes of intraservice time, as required to validate that CPT code 99152 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 services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99152) provided on June 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided from October 16, 2019 to October 21, 2019
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you feel the copayment is too high since you have paid a lower copayment for prior inpatient hospital stays. 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 $300 copayment per day for days 1-6 for inpatient hospital care. You have been asked to pay $1,500 for the inpatient hospital stay. $300 per day for 5 days' equals $1,500. 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 an inpatient hospital stay provided from October 16, 2019 to October 21, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKetamine for the enrollee.You asked the Plan to pre-approveKetamine. The Plan denied your request. The Plan says that this type of therapy is considered experimental and/or unproven.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ketamine. Our reviewer says that Ketamine is not medically reasonable and necessary for the enrollee in this case. Based on review the records and the literature provided by the manufacturer, this procedure is not indicated by the FDA for the treatment of Depressive Disorders or Anxiety Disorders. The use of this procedure is considered off label as Ketamine hydrochloride is considered for general anesthesia, induction of general anesthesia or procedural sedation. It's off label use include sedation, bronchospasm, acute pain moderate to severe and rapid sequence intubation, induction. Based on review of the records provided and the literature provided on the use of this procedure, it does not appear that this procedure is considered medically necessary for the treatment of depressive disorder due to no FDA indication and it would be considered experimental. Our physician reviewerfound that the enrollee's condition does not meet criteria for Ketamine.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine have not been met.Therefore, we decided that the Plan does not have to pre-approveKetamine for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the catheter replacement or removal provided on November 9, 2019.
You asked the Plan to waive the copayment for the catheter replacement or removal. You say that you had to return to correct the first procedure. You say that the cause and cost of the second procedure is not your responsibility. 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 $325 copayment for surgery at an outpatient hospital facility. You have been asked to pay a $325 copayment for the catheter replacement or removal. The catheter replacement or removal 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 for the catheter replacement or removal provided on November 9, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve MRI of the abdomen for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says that [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has hepatitis C, and a history of cirrhosis. The ultrasound has shown a dense hepatic parenchyma. This means the ultraouns is of limited value in excluding the most serious possibility given her history of hepatocellular carcinoma. MRI is the most sensitive means with which to evaluate for such a disease. This enrollee is at a high risk for this disease. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve MRI of the abdomen for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete maxillary denture and complete mandibular denture.
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that you need to get dentures. The Plan denied your request. The Plan says these services are not covered benefits under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the complete maxillary denture and complete mandibular denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) and gingival irrigation (D4921).You asked the Plan to pre-approvethe dental services. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the benefit limit has been exhausted for D4341 and D4921 is not listed as a covered benefit and is therefore not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Periodontal scaling and root planing is covered one procedure per quadrant every 2 years. Records show that this service was received February 7, 2020, therefore the frequency limit has been reached. D4921 is not listed as a covered benefit. The health plan contract says that any service not listed is not covered by the plan.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approveperiodontal scaling and root planing (D4341) and gingival irrigation (D4921).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for subsequent nursing facility care. You say that the services were provided and payment should be rendered. The Plan denied your request. The Plan says prior authorization was not requested or received for the services, therefore coverage criteria has not been met.
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 subsequent nursing facility care (99309) provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to a non-network provider.You asked the Plan to pre-approvethese services. You say that you should be able to chose your provider.The Plan denied your request. The Plan says the services are available 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-approvea referral to a non-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Left Heart Catheterization (93452).
You asked the Plan to pre-approve the Left Heart Catheterization. You say that the catheterization is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 Left Heart Catheterization. Our reviewer says that the left heart catheterization is not medically necessary. Our physician reviewer found based on the records the patient has increased coronary risk but no symptoms or findings suggestive of coronary ischemia being considered for high-risk non-cardiac liver transplantation surgery. In this circumstance if preoperative evaluation for coronary ischemia is thought to be medically necessary then stress testing is the most appropriate first step. The records do not support the medical necessity for coronary angiography in the absence of symptoms or noninvasive findings suggestive of coronary ischemia. Guidelines endorsed by several national organizations also do not consider screening coronary angiography appropriate in this setting. Assessment of pulmonary artery pressure prior to liver transplantation is appropriate and since unable to be estimated on echocardiography, right heart catheterization is reasonable and appropriate. 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 Left Heart Catheterization have not been met. Therefore, we decided that the Plan does not have to pre-approve a Left Heart Catheterization (93452).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lesion removal and wound repair provided on December 3, 2019 and December 4, 2019.You asked the Plan to waive the copayment for the lesion removal and wound repair. You say that the same surgery was done over two days. You say that you should not owe another copayment.The Plan denied your request. The Plan says the copayments 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 $295 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgical center.You have been asked to pay a $295 copayment for the lesion removal and a $295 copayment for the wound repair. The total amount you owe is $590 ($295/procedure x 2 procedures = $590). The lesion removal and wound repair fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the lesion removal and wound repair were separate procedures. 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 lesion removal and wound repair provided on December 3, 2019 and December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network orthopedic surgeon.
You asked the Plan to pre-approve these services. You say that you are having neck pain. The Plan denied your request. The Plan says the services are available 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 referral to an out-of-network orthopedic surgeon.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).You asked the Plan to pre-approveSNF admission. You say that the enrollee is not able to get up or walk on her own without assistance.The Plan denied your request. The Plan says the denial of authorization for SNF service is correct.The Plan must follow Medicare rules. Therules 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 wascorrect in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not beenmet.Therefore, we decided that the Plan does not have to pre-approveadmission to a Skilled Nursing Facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and the extraction (D7140) provided on December 19, 2019.You asked the Plan to pay for the dental services. You say that you went to the clinic for an extraction. You say that the clinic did not run the insurance status to see if there was any money left to cover the procedures. You also say that if you knew there was no more money to cover this procedure, then you would have waited until next year.The Plan denied your request. The Plan says there is an annual maximum benefit of $2,000. The Plan also says that the annual maximum benefit has been exhausted prior to the processing of this claim.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and the services are listed as covered, the annual maximum benefit of $2,000 has been exhausted. The Evidence of Coverage clearly states that after the annual maximum is exhausted, any remaining charges are your responsibility. Therefore, we decided that the Plan does not have to pay forthe limited oral evaluation (D0140) and the extraction (D7140) provided on December 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
You asked the Plan to pre-approve the compression stockings. You say that the enrollee requires the stockings for lower extremity edema. The Plan denied your request. The Plan says gradient compression stockings A6545 are non-covered when there is no qualifying wound.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora 3D rendering and interpretation (76376) provided September 3, 2019. You asked the Plan to pay forthe 3D rendering and interpretation. You say that the service was medically necessary and properly billed.The Plan denied your request. The Plan says 3D rendering and interpretation is not separately payable.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 76376 is not supported in the medical record. Specifically, under Medicare rules, separate payment cannot be made for 3D rendering and interpretation. Payment is bundled with the primary procedure. Based on thisinformation, we decided that Medicare rules for coverage of the 3D rendering and interpretation have not been met.Therefore, we decided that the Plan does not have to pay fora 3D rendering and interpretation (76376) provided September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 1, 2019 to June 13, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this service because it is not appropriate for the type of bill that was billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with an invalid type of bill.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 1, 2019 to June 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ciprofloxacin-Dexamethasone Drops, Oxymetazoline Spray and Hydrocodone-Acetaminophen provided on November 20, 2019.
You asked the Plan to pay for these drugs. You say that you cannot afford this. The Plan denied your request. The Plan says that self-administered drugs are not covered by the 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 pay for the Ciprofloxacin-Dexamethasone Drops, Oxymetazoline Spray and Hydrocodone-Acetaminophen provided on November 20, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.