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

We decided that the Plan does not have to pay for anesthesia services (67500) provided June 10, 2020.
You asked the Plan to pay for anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not filed correctly.
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 67500 is not supported in the medical record. Specifically, a required anatomical modifier was not included. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (67500) provided June 10, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography (77067) and screening digital breast tomosynthesis (77063) provided on July 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for mammography and breast tomosynthesis. You say that you were misled and thought the service would be covered. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.
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 the screening mammography (77067) and screening digital breast tomosynthesis (77063) provided on July 20, 2020 by an out of network (OON) provider.
Your complaint about potentially being told the provider you were seeing accepted your Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of skin and tissue and removal of tissue from wounds (11042, 97597) provided on July 14, 2020, to July 28, 2020.
You asked the Plan to waive the copayment for the surgical procedures. You say that you disagree with the copayment as charged. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 $400 copayment for outpatient hospital surgery services. You have been asked to pay a $400 copayment for the surgical procedures. These procedures fall within the outpatient hospital surgery 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 the removal of skin and tissue and removal of tissue from wounds (11042, 97597) provided on July 14, 2020, to July 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable gas oxygen system (K0738) and oxygen concentrator (E1390) provided on March 6, 2020 by anout of network (OON) provider.You asked the Plan to pay forportable gas oxygen system and oxygen. You say that you were unaware the provider was out-of-network.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe portable gas oxygen system (K0738) and oxygen concentrator (E1390) provided on March 6, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray and surgical extraction provided on July 
17, 2020. 
 
You asked the Plan to pay for the panoramic x-ray and surgical extraction.. You say that you received an x-ray 
because your regular provider's office was closed. The Plan denied your request. The Plan says panoramic x-
ray is not a covered benefit under your dental plan. The Plan also says that the $337.25 deductible was applied 
correctly. 
 
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, panoramic x-ray is not among those 
covered under this benefit. Though the Plan offers a dental benefit in excess of Medicare coverage, you also 
have a $350 deductible that you must pay before the Plan will pay their share of the cost for your covered 
dental services. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and surgical 
extraction provided on July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRFadmission and services.You asked the Plan to pre-approve IRF care. You say that the enrollee needs inpatient rehabilitationbecause she had a recent stroke. The Plan denied your request. The Plan says basedon Medicare guidelines, the IRFservices you and/or your provider are requesting do not meet the requirements for approval.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for abdominal pain and vomiting. The medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, includingeither physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveIRFadmission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKeytruda.You asked the Plan to pre-approveKeytruda. The Plan denied your request. The Plan says the clinical value and effectiveness of Keytruda in metastatic rectal cancer have not been demonstrated.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our physician reviewer found that the enrollee has metastatic colon cancer. Keytruda in addition to Regorafenib is not compendia based or literature supported for the enrollee's condition.The documentationdoes notsupport that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefour skilled nursing visits, eight occupational therapy visits, six additional physical therapy visits, and four additional home health aide visits.You asked the Plan to pre-approvethese service. You say that you need these additional home health services and that they are medically necessary.The Plan denied your request. The Plan says four physical therapy visits and four home health aide visits have been approved to manage your medical condition.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that these services are not medically necessary. Our physician reviewer found the documentation does not support that the member requires skilled nursing services or skilled rehab services beyond what has been approved by the health plan to provide treatment that is medically necessary. The member does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration.  The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these service have not been met.Therefore, we decided that the Plan does not have to pre-approvefour skilled nursing visits, eight occupational therapy visits, six additional physical therapy visits, and four additional home health aide visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride application (D1208) provided on May 27, 2020.
You asked the Plan to pay for the fluoride application (D1208). You say that you weren't aware this service wasn't covered by insurance. You say that you don't have the money to pay. The Plan denied your request. The Plan says the maximum benefit for this service has been met.
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, you also have a maximum benefit of one fluoride treatment every year. The Plan paid for the fluoride treatment provided on February 26, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the fluoride application (D1208) provided on May 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for surgery services you received in a dermatologist's office on June 19, 2020.
You asked the Plan to waive the cost sharing for the surgery services. You say that you thought all cost sharing was covered through the end of the year. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that the copayment waiver only applies to primary care, outpatient behavioral health, and telehealth visits. This waiver does not apply to specialist services or to surgery services. The Plan says that you had not yet met your annual deductible when you had these services, so you are responsible for the deductible plus the applicable copayment.
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 have a $100 and you must pay a $50 copayment for surgery services in a specialist's office after the deductible is met. You have been asked to pay your $100 deductible and a $50 copayment for the surgery services. 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 sharing for surgery services you received in a dermatologist's office on June 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a skilled nursing stay provided by a participating provider on May 14, 2020 to June 9, 2020.
You asked the Plan to waive the copayment for a skilled nursing stay. You say that you would like this reprocessed. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-100 for skilled nursing facility (SNF) care/in-network. You have been asked to pay a $0 copayment per day for days 1-20. There is a $178 copayment per day for days 21-29 for a skilled nursing stay. The total amount you are being asked to pay is $1,424 ($178 x 8 days = $1,424). A skilled nursing stay falls within the skilled nursing facility (SNF) care/in-network 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 a skilled nursing stay provided by a participating provider on May 14, 2020 to June 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab testing provided to the enrollee on May 13, 2020.You asked the Plan topay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says to report a CGP, service providers should use CPT code 81479 (for the entire multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Coverage of CGP is limited to one test per specimen and precludes the use of any other molecular testing on the specimen.The Plan states the claim submitted does not include the required codes. 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 claim submitted lacks the codes required for this testing to be paid. Therefore, we decided that the Plan does not have to pay forlab testing provided to the enrollee on May 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable gas oxygen system (K0738) and oxygen concentrator (E1390) provided on June 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forportable gas oxygen system and oxygen. You say that you were unaware the provider was out-of-network.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe portable gas oxygen system (K0738) and oxygen concentrator (E1390) provided on June 6, 2020 by an out of network (OON) provider.
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 you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 topre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee required supervision for functional mobilityincluding walking to 200 feet with a rolling walker. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis, at a SNF 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by you on July 6, 2020.You asked the Plan to pay forthe ambulance services. You say that you were following the COVID executive order for treatment in place.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 6, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by you on July 6, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve the epidural steroid injection (62321). We decided that the Plan
does not have to pre-approve the cervical facet injection (64490, 64491).
You asked the Plan to pre-approve the epidural steroid injection (62321). You say that the denial appears to be
inappropriate and not based on medical necessity and indications. The Plan says that the requested procedure is
not medically necessary because the records do not show that the enrollee have pain that does not travel down
their arms or legs.
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 epidural steroid injection (62321).
Our reviewer says that this enrollee partially meets the Medicare criteria for the requested items Our physician
reviewer found there is a specific limitation that epidural steroid injections and facet injections cannot be
performed on the same day. Further, the LCD and NCD specifically states that there is exclusion criteria for
performing a diagnostic MBB in the presence of a radiculopathy. While the epidural steroid injection is
medically reasonable and necessary, the cervical facet injection does not meet the criteria of the LCD and is
therefore, deemed not medically reasonable or necessary at this point.
We decided that the Plan has to pre-approve the epidural steroid injection (62321).
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary
are not covered.
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 epidural steroid injection (62321) have been met. Therefore, we decided that
the Plan has to pre-approve the epidural steroid injection (62321).
We also decided that the Plan does not have to pre-approve the cervical facet injection (64490, 64491).
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary
are not covered.
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 cervical facet injection (64490, 64491) have not been met. Therefore, we
decided that the Plan does not have to pre-approve the cervical facet injection (64490, 64491).
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.