Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that iron infusion is covered when specific criteria are 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 denyingthe request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not support that the enrollee has chronic renal disease, is on hemodialysis, or has failed a trial of oral iron supplementation. The records do not support that the Injectafer is reasonable or medically necessary for the enrollee at this time.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveInjectafer.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional unit of CPT 73080 billed on October 21, 2019.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says only one unit of this service is supported.
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 73080 is "Radiologic examination, elbow; complete, minimum of 3 views". We find that CPT code 73080 is not supported in the medical record. Specifically, the records provided show that one wrist x-ray was provided on the date of service in question. This means that only one unit of CPT 73080 is supported. The plan has already processed and paid for CPT 73080 for October 21, 2019. The additional unit of CPT 73080 is not supported by the records provided. Therefore, we decided that the Plan does not have to pay for the additional unit of CPT 73080 billed on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy rendered on February 6, 2019 to February 28, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you thought the costs had been paid. The Plan denied your request. The Plan says the coinsurance was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for in-network radiation therapy.
Review of the file shows that you received radiation therapy from February 6, 2019 to February 28, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $680.43. These services fall within the in-network radiation therapy 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. The file shows that you had not met your maximum out-of-pocket amount at the time this claim was processed. Therefore, we decided that the Plan does not have to waive the coinsurance for the radiation therapy rendered on February 6, 2019 to February 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from October 31, 2019 to November 4, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that it was not your fault that you needed emergency surgery and disagree with the charges. 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 $300 copayment per day for days 1-5 for inpatient hospital care. You had an inpatient hospital stay from October 31, 2019 to November 4, 2019. Therefore, you are responsible to pay a $300 copayment for days 1-4 (October 31, 2019 to November 3, 2019). $300 (copayment) x 4 (inpatient days) = $1,200. You have been asked to pay the total copayment amount of $1,200 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay from October 31, 2019 to November 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B drug provided on January 16, 2020.You asked the Plan to waive the coinsurance forthe Part B drug. You say that you are going through a financial hardship due to the cost of your medication. 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). Your contract with the Plan clearly says that you must pay 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $176.43 which is 20% coinsurance of the allowed amount for the Part B drug. The allowed amount is $882.13. ($882.13 x 20% = $176.43). The Part B drug falls within the "Medicare Part B Prescription Drugs" 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 contractualobligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe Part B drug provided on January 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from February 2, 2020 to February 9, 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. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from February 2, 2020 to February 9, 2020. Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the prosthetic 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 neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network providers available to you that can provide the items you are requesting.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 the prosthetic services to be provided by an out of network (OON) provider.Your complaint about the 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 suction catheters (A4624) per day for an additional 10 months.
You asked the Plan to pre-approve 10 suction catheters (A4624) per day for an additional 10 months. You say that 10 suction catheters (A4624) per day are medically necessary. The Plan denied your request. The Plan says 10 suction catheters (A4624) per day are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare covers suction catheters (A4624) when they are medically necessary and used with a medically necessary E0600 pump. Code A4624 is only covered for beneficiaries with a tracheostomy. More than three A4624 catheters per day will be denied as not reasonable and necessary for tracheostomy suctioning. Based on this information, we decided that Medicare rules for coverage of 10 suction catheters (A4624) per day for an additional 10 months have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 suction catheters (A4624) per day for an additional 10 months.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-elastic conforming bandage (A6446), non-waterproof tape (A4450), and sterile gauze (A6402) provided on January 3, 2020. You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the items were provided by an out of network provider at a non-participating facility, 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 provider and the facility in this case are not network providers with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the non-elastic conforming bandage (A6446), non-waterproof tape (A4450), and sterile gauze (A6402) provided on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe enteral formula, enteral feeding supply kit and IV pole provided to the enrollee from January 3, 2020 to January 27, 2020.You asked the Plan to pay forthese services. The Plan denied your request. The Plan says that this is included in Part A SNF payment.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for items furnished to an enrollee. The facility must furnish all necessary covered services and supplies to the enrollee either directly or under arrangements made with outside providers. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility.Therefore, we decided that the Plan does not have to pay forthe enteral formula, enteral feeding supply kit and IV pole provided to the enrollee from January 3, 2020 to January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hand wrist orthosis (L3916) provided on January 23, 2020.
You asked the Plan to pay for the hand wrist orthosis. You say that you would like reconsideration because the billed supplies are medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hand wrist orthosis have not been met. Specifically, the record indicates that the Plan requested progress notes to indicate the provider discussed the need for the billed supply code along with documentation of the duration of the member's condition, clinical course (worsening or improving), prognosis, nature and extend of functional limitations, other therapeutic interventions and results and previously purchased DME items related to the billed items. There is insufficient information to verify the billed supply codes. Therefore, we decided that the Plan does not have to pay for hand wrist orthosis (L3916) provided on January 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forwound debridement provided from December 3, 2019 to December 23, 2019.You asked the Plan to waive the copayments forwound debridement. You say that you disagree with the hospital charges because you were not inpatient.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 $100 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received wound debridement from December 3, 2019 toDecember 23, 2019 for a total of 4 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $100 copayment per each service. The total amount you owe is: $400. You have been asked to pay the totalcopayment amount of $400 for wound debridement. Wound debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forwound debridement provided from December 3, 2019 to December 23, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on March 1, 2019.You asked the Plan to pay forthis service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plandenied your request. The Plan says the service wasprovided by an out of network 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service.Therefore, we decided that the Plan does not have to pay forthe subsequent nursing facility care (99309) rendered by the out of network (OON) provider on March 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 14, 2019. You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services were billed with an inappropriate modifier combination. 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 J1100 and J0702 are not supported in the medical record. Specifically, the documentation provided does not indicate the specific injection that was administered. Based on this information, we decided that Medicare rules for coverage have not been met. Medicare rules say that modifier -50 is used to report bilateral procedures that are performed at the same operative session as a single line item. Do not use modifiers RT and LT when modifier -50 applies. We find that CPT code 73580 was billed as two line items, with modifier 50 as well as RT and LT modifiers. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis provided on January 10, 2020, January 13, 2020 and January 15, 2020.
You asked the Plan to waive the coinsurance for dialysis. You say that dialysis is a necessity. You say that you cannot afford these bills. The Plan denied your request. The Plan says the coinsurance applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare-covered benefits. Covered services include outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3).
You have been asked to pay a total of $171 for dialysis.
Dialysis falls within the "Services to Treat Kidney Disease" 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 coinsurance for dialysis provided on January 10, 2020, January 13, 2020 and January 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Train of Four testing (95999) provided October 30, 2019.You asked the Plan to pay forTrain of Four testing. You say that the service was medically necessary.The Plan denied your request. The Plan says payment for this service is bundled with another 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 95999 has a bundled relationship with the intraoperative neuromonitoring services already paid. 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 forTrain of Four testing (95999) provided October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Observation Care (99220) provided May 25, 2019.You asked the Plan to pay for the observation care. You say that the services were not a duplicate.The Plan denied your request. The Plan says the claim submitted is a duplicate of another claim.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 99220 is not supported in the medical record. Specifically, the record shows the claim as submitted is a duplicate of an already paid claim. Based on this information, we decided that Medicare rules for coverage of the observation care have not been met.Therefore, we decided that the Plan does not have to pay for Observation Care (99220) provided May 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that this lab is contracted with the facility to provide the lab services to the residents. 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 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 lab work provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 16, 2020.
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an office visit provided on January 16, 2020.