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

We decided that the Plan does not have to waive the copayment for the sleep study provided on February 4, 2020. 
 
You asked the Plan to waive the copayment for the sleep study. You say that you were told Medicare should pay the cost. You say you were not asked for a copayment at the time of your visit. 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 a $275 copayment for Medicare-covered sleep studies and stress tests. 
 
You have been asked to pay a $275 copayment for the sleep study. The sleep study falls 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 the sleep study provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity study (93971) provided on January 29, 2020. 
 
You asked the Plan to pay for the extremity study. You say that you would like reconsideration because this claim was denied as a duplicate in error. The Plan denied your request. The Plan says the submitted documentation supports 1 unit of CPT code 93971 which was previously approved/paid. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the extremity study have not been met. Specifically, the record indicates that 1 unit of CPT code 93971 has been paid. There is no additional documentation to support an additional study. Therefore, we decided that the Plan does not have to pay for an extremity study (93971) provided on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork provider on October 17, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. 
 
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on October 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on October 24, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for skilled nursing services. You say that these services are provided in good faith. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring facility is out-of-network. The Plan says that 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 skilled nursing services provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has shortness of breath, a
history of pneumonia and chronic obstructive pulmonary disease who has failed Breo inhaler treatment due to
problems with manual dexterity. He has not tried and failed the Plan's required drug of Perforomist. The
records do not show that the required drug would be less effective or contraindicated; therefore, Brovana is not
reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Brovana.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these 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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.  
 
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 the services are not medically necessary. Our physician reviewer found the enrollee has cancer of an unknown primary with liver metastases. Carboplatin and Taxol were started and the plan is to add Keytruda. Keytruda is not FDA-approved for cancers of occult primary. The enrollee's tumor is not MMR deficient or MSI-HIGH. The use of Keytruda is not supported by major drug compendia or the medical literature and is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on December 7, 2019. 
 
You asked the Plan to waive the copayment for the ambulance ride. You say that you did not receive services during the ambulance ride and you cannot afford this bill. 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 a $350 copayment per one way trip for emergency and non-emergency ambulance services.  
 
You have been asked to pay a $350 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The medical record shows you were examined during your ambulance ride. 
 
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 ambulance ride provided on December 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for parental nutrition solution provided from November 13, 2019 to November 19, 2019. 
 
You asked the Plan to pay for parental nutrition solution. You say that the Plan should pay this claim. The Plan denied your request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.  
 
The record shows that the Plan made several attempts to obtain the physician order documentation for the items at issue in this appeal. The record does not contain a valid physician order the supplies provided in this case. The order form is dated after the date of service. Therefore, we decided that the Plan does not have to pay for parental nutrition solution provided from November 13, 2019 to November 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on November 26, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the doctor has two specialties. You say that you should be refunded. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $40 copayment per visit for Medicare-covered specialty care services. The enrollee has been asked to pay a $40 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visit was with a cardiologist, which is considered a specialist. 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 office visit provided on November 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 20, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the requested seat is needed to make daily tasks easier for you and you asked the Plan to reconsider its denial. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure. 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested Vertiflex procedure is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex procedure is not medically necessary. 
 
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 a Vertiflex procedure. Our reviewer says that the requested Vertiflex procedure is not medically necessary. Our physician reviewer found this enrollee has lumbar spinal stenosis with neurogenic claudication. He had 2 lumbar epidural steroid injections which provided only limited duration relief. The request is for insertion of Vertiflex interspinous device. 
 
This is still considered an experimental/investigational device because there has not been a rigorous head to head trial between this device and decompressive surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment the emergency room visit provided on January
8, 2020.
You asked the Plan to waive the copayment the emergency room visit. You say that you should not be
responsible for the copayment. 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 a $90
copayment for Medicare-covered emergency room visits.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency 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 the emergency
room visit provided on January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on July 1, 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 20611 is not 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 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. We find that CPT code 20611 is not supported in the medical record. Specifically, there is no documentation of permanently recorded images to support the billed services. 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 surgical services rendered on July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for local anesthesia (D9210) autogenous connective tissue graft (D4273) biologic material to aid in soft and osseous tissue regeneration (D4265) provided January 2, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were encouraged to wait until 2020 for gum surgery so you would be eligible for the $1500 coverage. You would like to be refunded $1500 of your periodontal bill that is on file. The Plan denied your request. The Plan says these services are not covered under the plan benefits. 
 
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. Services not listed under the Description of Benefits are not covered by the plan. Services not listed is not covered by the plan. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for local anesthesia (D9210) autogenous connective tissue graft (D4273) biologic material to aid in soft and osseous tissue regeneration (D4265) provided January 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 enrollee was medically stable with no evidence of need for supervision by a
physical medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. The enrollee may
benefit from further physical therapy (PT) and occupational therapy (OT) but does not require an intensive
therapy program. IRF admission is not medically necessary based on the enrollee's current functional status and
medical stability.
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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D7210, D6010, D4266, D7953) provided March 2, 2019.
You asked the Plan to pay for the dental services. You say that the services were needed due to a fall and should be covered. The Plan denied your request. The Plan says the records provided from the Emergency Room do not note dental injuries related to the fall. The requested services are not eligible for coverage under the Medical benefit.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for dental services (D7210, D6010, D4266, D7953) provided March 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 29, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the dneial. The Plan denied your request. The Plan says procedure code 82679 is not 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 82679 is assay of estrone. 
 
We find that CPT code 82679 is not supported in the medical record. Specifically, there is no documentation of lab results for an assay of estrone. 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 laboratory services rendered on October 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for injections (J1100, J0131) provided
September 30, 2019.
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived.
The Plan denied your request. The Plan says the correct cost-sharing was 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 20%
coinsurance for Part B drugs.
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B 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 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 injections (J1100, J0131)
provided September 30, 2019.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for services provided on May 24, 2019. 
 
You asked the Plan to pay for the non-emergency transportation. You say that you were told the transport to the skilled nursing facility would be covered. The Plan denied your request. The Plan says that wheelchair van services are not covered. 
 
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 non-emergency transportation, from a hospital to a skilled nursing facility, by a contract provider. The record shows it was a stretcher van from a contracted provider. You were on a stretcher and assumed it was an ambulance type vehicle. The file does not show that the Plan provided notice that the non-emergency transportation would not be covered. Under Medicare rules, this means the non-emergency transportation is considered approved by the Plan. Therefore, we decided that the Plan has to pay for services provided on May 24, 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.