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

We decided that the Plan does not have to waive the cost share for the chemotherapy administration,
subcutaneous or intramuscular (96402 x 3), degarelix injections (J9155 x 3), and the office visit (99214)
provided from January 20, 2021, through March 24, 2021.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the
services 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). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered Part B drug; for the administration of that drug, you will pay the cost-sharing that applies to primary care provider services, specialist services, or outpatient hospital services. Enrollees must pay a 20% coinsurance for each Medicare-covered chemotherapy drug and the administration of that drug. Additionally, enrollees pay a $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay $252.78 which includes a $45 copayment for the office visit, the Medicare allowable amount of ($39.11 x 20% coinsurance=$7.82 x 3= $23.46) for the chemotherapy administration and the Medicare allowable amount of ($307 x 20% coinsurance=$61.44 x 3=$184.32) for the Medicare Part B drug injections provided on January 20, 2021, February 24, 2021, and March 24, 2021. 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 for the chemotherapy administration, subcutaneous or intramuscular (96402 x 3), degarelix injections (J9155 x 3), and the office visit (99214) provided from January 20, 2021, through March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 4, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim indicates that the specimen was collected in a laboratory setting while the records indicate it was obtained in an office setting.

The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, this claim has been billed with a laboratory place of service code while the records indicate that the member's face-to-face encounter took place in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found based on the documentation provided, you no
longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have
documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are
not shown to be required to establish a maintenance program or to prevent deterioration of your condition. At
this point, your care needs are custodial and, as a practical matter, can be provided at a lower level of 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist from April 22, 2021, to April 27, 2021.

You asked the Plan to pay for the out-of-network dental services. You say that you could not find an in-network dentist without a long wait because of the pandemic, so you saw the dentist you have seen for 26 years. The Plan denied your request. The Plan says out-of-network dental services are 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. 

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. There is no evidence that you contacted the Plan prior to receiving these services for assistance in finding a network provider who could provide care. Therefore, we decided that
the Plan does not have to pay for dental services you received from an out-of-network dentist from April 22, 2021, to April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81401, 81403, 81404, 81405, 81406, 81407,
81408) provided February 10, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment panels except for the standard lipid panel for patients with suspected or documented
cardiovascular disease.
We looked at the file and Medicare rules. The records show the procedure at issue is a cardiovascular risk
assessment panel. This service is non-covered. Based on this information, we decided that Medicare rules for
coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab
services (81401, 81403, 81404, 81405, 81406, 81407, 81408) provided February 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (29822) provided on March 12, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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. In this case, we have confirmed that code 29822
has a bundled relationship with code 29824 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the services (29822) provided on March 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit, includes a personalized prevention
plan of service (pps), subsequent visit (G0439) provided on February 24, 2021, by an out-of-network (OON)
provider.
You asked the Plan to pay for the annual wellness visit. You say that you should not need prior authorization
for an annual wellness exam. The Plan denied your request. The Plan says the service was provided OON
without prior authorization and therefore is not covered.
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 had network providers
available who could have provided 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 the annual wellness visit, includes a personalized
prevention plan of service (pps), subsequent visit (G0439) provided on February 24, 2021, by an out-ofnetwork
(OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 28, 2021 by a nonparticipating
provider.
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 were rendered by a non-participating provider without 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 had network providers
available who could have provided 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 the laboratory services provided on April 28, 2021
by a non-participating provider.
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. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee's needs can be met at a lower level of 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services provided to the enrollee on December 11, 2020.
You asked the Plan to pay for the neurology services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules also state that for Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has been met. 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 neurology services. Our reviewer says that the services is not medically necessary. Our reviewer found the documentation did not corroborate that all services were
billed correctly. Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been 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 neurology services have not been met. Therefore, we decided that the Plan does not have to pay for neurology services provided to the enrollee on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the routine exam, frame and lenses provided by a
non-preferred provider on March 10, 2021.
You asked the Plan to reimburse you for the eye exam and eyeglasses. You say that you would like the claim considered for reimbursement. The Plan denied your request. The Plan says the contract does not allow coverage for frames and lenses with an out-of-network provider.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when you must use the preferred participating provider. We looked at the file and the Plan's rules. Services were provided by a non-network participating provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for the routine exam, frame and lenses provided by a non-preferred provider on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on February 5, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic testing provided on February 5, 2020
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the ventilator supplies provided on December 23, 2020.

You asked the Plan to pay for the ventilator supplies. You say that these supplies are medically necessary for use with the device. The Plan denied your request. The Plan says that there is not an order form for each supply provided with the ventilator. As such, they cannot be reimbursed.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided a cogent denial rationale for the supplies included in the initial delivery of the rented respiratory assist device. The Plan states that there is no signed physician order for these items which is required for payment. However, there is a signed order form for the device itself, and the rental of this device has been reimbursed by the Plan. It is not reasonable for each individual supply for use with the device to be listed on the order form for a device. We find that the denial of payment for these items is not substantiated. Therefore, we decided that the Plan has to pay for the ventilator supplies provided on December 23, 2020.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for topical application of fluoride varnish (D1206) provided March 30, 2021.

You asked the Plan to pay for the dental services. You say that this is the same dentist you were seeing last year and your claims were at least partially covered. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider.

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. The health Plan contract says that services performed by an out of network dentist, if your plan does not have out of network coverage is not covered. 

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 pay for topical application of fluoride varnish (D1206) provided March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile needles rendered on December 14, 2020.

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 separately payable.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. 

We looked at the file and Medicare rules. Billed procedure code A4215 (needle, sterile, any size, each) has a status indicator of X and is statutorily excluded from Medicare payment. Therefore, we decided that the Plan does not have to pay for the sterile needles rendered on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on March 10, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because a two or more genes in the same panel are considered a single procedural service so one procedure code must be submitted for the panel.
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays 2 or more genes in parallel, then those genes will be considered part of the same panel and 1 procedure code must be submitted for the panel.
We looked at the file and Medicare rules. This panel testing must be billed with 1 procedure code; therefore, the testing has not been billed with the appropriate coding. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided on March 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz (J7321).
You asked the Plan to pre-approve step therapy services. You say that Supartz injections would slow down the process of Osteoarthritis. The Plan denied your request. The Plan says the request for coverage under Medicare part B was denied because the enrollee did not meet step therapy requirements.
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 step therapy services. Our reviewer says that the service is not medically necessary. Our physician reviewer found a request has been made for Supartz, a hyaluronic acid injection, to treat osteoarthrits. The health plan requires that other forms of hyaluronic acid be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of medication. There is no evidence that the enrollee has tried and not responded to these other forms of medication. There is no documentation as to why these other forms of medication would not be expected to be safe and effective for the enrollee. Therefore, the requested Supartz is not shown to be currently medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of step therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz (J7321).