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

We decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a second opinion office visit. You say that the member wants a second opinion. You say that the member will get the surgery within the referral circle. The Plan denied your request. The Plan says there are multiple in-network providers available for a second opinion.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a second opinion office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the clinic services rendered on August 12, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0463 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes G0463 and 97162. Code G0463 is a column II code with a modifier indicator of 1 when billed with column I code 97162. Code G0463 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the clinic services rendered on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two additional transforminal epidural steroid injections
You asked the Plan to pre-approve the additional injections. You say that this is medically necessary. The Plan denied your request. The Plan says the requested number of injections exceed the frequency limitations.
The Plan must follow Medicare rules. Medicare rules say that no more than transforaminal injections may be covered for a single session. The additional requested injections go above the benefit provided by Medicare. The plan has already approved two injections for this single session. Based on this information, we decided that Medicare rules for coverage of the additional injections have not been met. Therefore, we decided that the Plan does not have to pre-approve two additional transforminal epidural steroid injections
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the outpatient hospital services you received from July 3, 2019, to July 4, 2019.
You asked the Plan to waive the copay for the services provided. You say that you are getting bills that the plan should take care of. The Plan denied your request. The Plan says the cost share was applied in accordance with your benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copay for outpatient hospital services. You have been asked to pay a $200 copay for the services provided. The records provided do not show that you were admitted as an inpatient. The services fall within the outpatient hospital 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 copay for the outpatient hospital services you received from July 3, 2019, to July 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from June 29, 2019 to July 9, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that this should have been billed as a Skilled Nursing Facility and not an Inpatient Rehabilitation. You say you have already paid for a previous inpatient hospital stay. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $350 copayment for each day, day(s) 1-5 and a $0 copayment, days 6+. The enrollee has been asked to pay a $350 copayment for each day of the first 5 days of the inpatient hospital stay. ($350 x 5 = $1,750). The inpatient hospital stay falls within the "Inpatient hospital care" benefit category. The record shows the services were received at an inpatient rehabilitation hospital.
This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from June 29, 2019 to July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forwound care provided on October 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forwound care. You say that prior authorization was not obtained because waiting on wound care would cause more complications.The Plan denied your request. The Plan says no prior authorization was obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providersonly 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 forwound care provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis 
You asked the Plan to pay for the ankle foot orthosis (L1971). You say that the orthosis was medically
necessary. The Plan denied your request. The Plan says criteria for the orthosis was not 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 ankle foot orthosis (L1971). Our
reviewer says that the orthosis was not medically necessary. Our physician reviewer found the enrollee's chief
complaint was ankle pain. The documentation in the case file does not support that the requested ankle/foot
orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria
established by the LCD. A physical examination of the ankles and feet would reasonably be required to
adequately assess whether the coverage criteria were met. The documentation does not support that the
ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a
credible physical examination of the ankles and feet.
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 ankle foot orthosis (L1971) have not been met. Therefore, we decided that
the Plan does not have to pay for the ankle foot orthosis
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on September 27, 2019 and billed under code 99291.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 99291 (1 Unit) remains not supported. CPT code 99291 represents critical care, evaluation and management of the critically ill or critically injures patient, for the first 30-74 minutes. The documentation submitted do not include a critical care progress note for the billed date of service of September 27, 2019; therefore, 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.Medicare rules also state the medical records provided must support the services billed. Medicare rules say that if a specific code has time reporting requirements attached, those requirements must be clearly reflected in the medical records to support payment. In this case, the CPT Code Manual definition of code 99291 is a critical care, evaluation and management of an enrollee for the first 30-74 minutes.The medical records provided do not show the provider billing code 99291 recorded a time of 30-74 minutes with the enrollee on the date in question. Medicare billing criteria for code 99291were not met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on September 27, 2019 and billed under code 99291.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 19, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test (G0483) provided on March 22, 2019.You asked the Plan to pay for the drug test. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare's policies.We find that CPT code G0483 is not supported in the record. Specifically, the submitted toxicology profile indicates that the profile is effective for one year as of the date signed. This profile was signed on February 21, 2018. The date of service in question is March 22, 2019 rendering the submitted profile invalid. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for a drug test (G0483)provided on March 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient shoulder injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says there is no support in the literature for this intervention in the management of chronic shoulder pain.
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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found intra-articular injection is the standard of care for arthritis/bursitis and is medically necessary and reasonable. A suprascapular nerve block is indicated only in cases of adhesive capsulitis where range of motion is planned. This is not documented here. The requested procedure is not medically reasonable or necessary. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient shoulder injections for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve a CT scan. You say that you would like to have this test done at UCI. You say that this is causing you a lot of stress. You say that you feel most comfortable at UCI. The Plan denied your request. The Plan says the CT scan can be performed by the facility.
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 CT scan to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve card for allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approvecard for allowance for healthy food purchases and/or electricity, water and/or phone bill payments. You say that you suffer from several conditions that makes you eligible for the supplementary benefits.The Plandenied your request. The Plan says the enrollee does not meet the criteria established to receive this benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for food purchases or utility bills but the plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case The plan covers these services whena member has one or morequalifying diagnoses, requires intense care coordination andhas high risk for hospitalizations or high risk for adverse health outcomes.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of card for allowance for healthy food purchases and/or electricity, water and/or phone bill payments have not been met.Therefore, we decided that the Plan does not have to pre-approvecard for allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are available in-network.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.You asked the Plan to pre-approve a CGM. You say that you do not want to finger stick test because you bleed too long afterwards.The Plan denied your request. The Plan says the record shows you are not insulin treated three or more times a day and only test twice a day.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Documentation from your practitioner does not support the criteria. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met.Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring (CGM) system.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for Acetylcysteine.You asked the Plan to reduce the cost share forAcetylcysteine. The Plan denied your request. The Plan says the enrollee cannot get a tiering exception for very high cost drugs on a specialty tier.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 5% coinsurance for Medicare Part B drugs at a pharmacy for Medicare Part B prescription drugs. The enrollee has been asked to pay a 5% coinsurance for Medicare Part B drugs at a pharmacy for Acetylcysteine. Acetylcysteine falls within the Medicare Part B prescription drugs benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that thePlan does not have to reduce the cost share forAcetylcysteine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 9, 2019.You asked the Plan to pay for HBO therapy. You say that this was medically necessary.The Plan denied your request. The Plan says the enrollee has skin ulcers.The Plan follows Medicare rules. Medicare rules say that HBO therapy is not covered for the treatment of cutaneous, decubitus, and stasis ulcers or chronic peripheral vascular insufficiency.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 HBO therapy. Our reviewer says that the criteria for coverage of HBO therapy have not been met. Our physician reviewer found the records show that the enrollee has painful skin ulcers of the extremities, torso, pannus, and penis and calciphylaxis. This description best is described by the non-covered "cutaneous, decubitus, and stasis ulcers" condition category as well as the non-covered "chronic peripheral arterial insufficiency" category.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met.Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 9, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay forradiology services (CPT 74420 provided to the enrollee on November 12, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says that it is inappropriate to submit multiple claims for the professional component (modifier 26) of the same diagnostic test or radiology procedure, as this service is only performed once by a single provider.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 74420 is "Urography, retrograde, with or without KUB."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 services. Our reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found the documentation shows that an x-ray was performed on 11/12/2019. This x-ray appears to have been interpreted by provider X, but was billed under provider Y's name with the modifier Q6. The health plan argues that provider Z has already been paid for this service. The documentation indicates that provider Z referred the enrollee for the service/x-ray, but there is no evidence that provider Z provided or interpreted the x-ray. Therefore, while the health plan has already paid provider Z, it appears that this payment may have been in error. The payment being requested by provider X/Y is supported.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 services have been met.Therefore, we decided that the Plan has to pay for radiology services (CPT 74420 provided to the enrollee on November 12, 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.