Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out of network (OON) provider.

You asked the Plan to pay for physical therapy. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are in-network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 physical therapy provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the allowance for eyeglasses purchased on November 6, 2020.
You asked the Plan to pay the allowance for eyeglasses. You say that you were told it would be processed under medical and you do not want to get charged. The Plan denied your request. The Plan says the maximum allowed under your benefit was exceeded.
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 eyeglasses and frames up to the plan allowance amount. We looked at the file and the Plan's rules. The record shows your full eyewear allowance was applied for a purchase of eyeglasses on February 26, 2020. Based on this information, we decided that the Plan's rules for coverage of your eyeglass allowance have not been met. Therefore, we decided that the Plan does not have to pay the $300 allowance for eyeglasses purchased on November 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the x-ray services provided on June 17, 2020.
You asked the Plan to waive the copay for the services provided. You say that you never received an x-ray. The Plan denied your request. The Plan says the claim processed 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 $45 copay for each basic imaging service. The medical records provided shows that you received x-rays of your bilateral shoulders. You have been asked to pay a $45 copay for the services provided. The services fall within the outpatient diagnostic tests 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 copay for the x-ray services provided on June 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic mammogram.

You asked the Plan to waive the copayment for a diagnostic mammogram. You say that the mammogram should be considered preventative, not diagnostic. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each basic radiology service.

The medical record shows that you received a diagnostic mammogram, due to abnormal imaging. Therefore, you are responsible to pay the $40 copayment.

You have been asked to pay a $40 copayment for a diagnostic mammogram. A diagnostic mammogram falls within the outpatient hospital observation 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 diagnostic mammogram.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 17, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that this was part of your annual wellness exam and you have never been charged in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for laboratory services. You received laboratory services on September 17, 2020. Laboratory services are not included in annual wellness visits. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on September 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services coded A0425 and ground mileage services coded A0429.

You asked the Plan to pay for the ambulance services coded A0425 and ground mileage services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 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 codes A0425 and A0429 are not supported in the medical record. Specifically, the enrollee was in an inpatient hospital status for this date of service. Once a member is admitted to an Inpatient Hospital or Critical Access Hospital (CAH), it may be necessary to transport the member to another hospital or other site temporarily for specialized care while the member maintains inpatient status with the original provider. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital or CAH service. Transportation services (A0021-A0999, S0207-S0215, S9960-S9961) are not separately payable from the payment to the inpatient institution. Based on this information, we decided that Medicare rules for coverage of the ambulance services coded A0425 and ground mileage services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services coded A0425 and ground mileage services coded A0429.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acute inpatient hospital care.
You asked the Plan to pre-approve continued services. You say that it is for the enrollee's wellbeing that she continues to get this level of care. The Plan denied your request. The Plan says custodial care is excluded from coverage.
The Plan must follow Medicare rules. The rules say that custodial care is not covered.
We looked at the file, and Medicare rules. The records provided show that the enrollee is no longer receiving acute care. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve continued acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network chiropractor.

You asked the Plan to pre-approve the referral. You say that you paid out-of-pocket for this provider previously, and the results were remarkable. The Plan denied your request. The Plan says there are 204 other in-network chiropractors within fifty miles of your zip code.

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 chiropractor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (J9173).

You asked the Plan to pre-approve Imfinzi. You say that the enrollee needs this drug. The Plan denied your request. The Plan says rules for pre-approval have not been met because the requested drug is for an off-label use not supported by the drug compendia.

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 Imfinzi. Our reviewer says that the requested drug is not medically necessary. Our physician reviewer found that the requested drug is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. Patients in the article cited by the prescriber were not pretreated with immunotherapy and did not show efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi (J9173).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Yervoy 50 mg/10 mL.

You asked the Plan to pre-approve Yervoy. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the use of Yervoy is experimental/investigational with the enrollee's condition.

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 Yervoy. Our reviewer says that Yervoy is not medically reasonable and necessary. Our physician reviewer found the use of Yervoy is not FDA-approved for the enrollee's metastatic non-small cell lung cancer. In addition, the use of Yervoy for the enrollee's condition is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy 50 mg/10 mL.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999), comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided on July 24, 2020.

You asked the Plan to pay for the preventive procedure, comprehensive oral evaluation, and prophylaxis. You say that the dentist will not provide any more work until they have been paid for these services. The Plan denied your request. The Plan says the preventive procedure is not covered. The Plan also says that you have exhausted your benefits for the comprehensive oral evaluation and prophylaxis.

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 preventive procedure (D1999) is not among those covered under this benefit. The contract also clearly states that comprehensive oral evaluation (D0150) is limited to one per calendar year, and prophylaxis (D1110) is limited to one every 6 months. The record shows that you received a comprehensive oral evaluation (D0150) and prophylaxis (D1110) on February 3, 2020, and your comprehensive oral evaluation (D0150) and prophylaxis (D1110) benefits have been exhausted.

Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999), comprehensive oral evaluation (D0150), and prophylaxis (D1110) provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the oxygen concentrator (E1390) provided on November 25, 2019.

You asked the Plan to pay for the oxygen concentrator. You say that you would like reconsideration because
you were told you would be refunded, but the provider will not do that until they are paid by the Plan. The Plan
denied your request. The Plan says that a corrected claim is needed before payment may be made.

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 oxygen concentrator by a contract provider. The file does not show that the Plan
provided notice that the oxygen concentrator would not be covered. Under Medicare rules, this means the
oxygen concentrator is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the
oxygen concentrator (E1390) provided on November 25, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3320, D3330).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the benefit has been exhausted for the 2021 plan year.

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 plan covers root canals once per year. 

A root canal was already approved for February 21, 2021. You would next be eligible for a root canal one year from whenever this root canal is received. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3320, D3330).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the MRA of the head (70544) provided on August 10, 2020.

You asked the Plan to pay for the MRA of the head. You say that you would like reconsideration because this service denied as a duplicate in error. The Plan denied your request. The Plan says that this service is bundled to another service billed on the same day by the same physician, or a physician of the same specialty in the same group, which is considered the same provider.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code 70544 is supported in the record. Specifically, the record shows that the column I and column II codes were rendered by separate providers. NCCI edits are applied to service billed by the same NPI. Based on this information, we decided that Medicare rules for coverage of the MRA of the head have been met. Therefore, we decided that the Plan has to pay for the MRA of the head (70544) provided on August 10, 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 the periodontal scalings and root planings of tooth #'s 2 and 3 in the upper right quadrant, and tooth #'s 14 and 15 in the upper left quadrant provided on October 14, 2020.

You asked the Plan to pay for the scalings and planings. You say that these services were necessary. The Plan denied your request. The Plan says your dental plan covers scaling and root planing, per quadrant, once every 36 months. The Plan also says that you were not eligible for scalings and root planings in the upper right or upper left quadrants on this date of service.

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, scaling and root planing is limited to once per quadrant every 36 months. The record shows that you received periodontal scaling and root planings in the upper right and upper left quadrants on September 19, 2018, and your non-surgical periodontics benefit for the upper left and upper right quadrants has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodontal scalings and root planings of tooth #'s 2 and 3 in the upper right quadrant, and tooth #'s 14 and 15 in the upper left quadrant provided on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that these services were medically necessary. The Plan denied your request. The Plan says there is no evidence prescribing physician saw the enrollee prior to rendering the services.

The Plan follows Medicare rules. Medicare rules say that for a spinal orthosis to be covered, the Medicare criteria cited in the Rules section must be met. 

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 lumbar-sacral orthosis. Our reviewer says that the orthotic is not medically reasonable and necessary. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacralorthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of a credible evaluation and a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cataract surgery rendered on September 2, 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 covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. 

In this case, the MUE for CPT code 66984 is 1. You billed 2 units of this code, exceeding the MUE. 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 cataract surgery rendered on September 2, 2020.