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

We decided that the Plan does not have to waive the coinsurance for an injection and copayment for an office
visit provided by a participating provider on January 7, 2020.

You asked the Plan to waive the coinsurance and copayment for an injection and an office visit. You say that
you already met your out-of-pocket maximum. The Plan denied your request. The Plan says the correct
coinsurance and copayment have been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs and a $15 copayment for physician/practitioner
services/specialist.

You have been asked to pay a 20% coinsurance of the allowed amount for an injection and a $15 copayment
for office visit. The total allowed amount is $238.72. The amount you are being asked to pay for injections is
$47.74 ($238.72 x 20% = $47.74). The total amount you are being asked to pay is $62.74 ($47.74 + $15 =
$62.74. An injection falls within the Medicare Part B prescription drugs benefit category and an office visit
falls within the physician/practitioner services/specialist 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 an injection and copayment for an office visit provided by a participating provider on
January 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services provided on September 9, 2019, through September 20, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the submitted claim form indicates thelaboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, POS 11.The Plan must follow Medicare rules. Medicare rules say that the POS code is generally used to reflect the actual setting where the beneficiary receives that face to face service.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the record indicates that the specimen was obtained in an office setting. The claim was billed using the place of service code for the laboratory.Therefore, we decided that the Plan does not have to pay forlaboratory services provided on September 9, 2019, through September 20, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 18, 2020.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 servicesat 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 subsequent nursing facility care provided on May 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveLivalo tab 4mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis medication does not fall under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveLivalo tab 4mg for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on June 26, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe lab services provided on June 26, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 18, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in a home setting, which would be indicated by POS code 12. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the application of vein wound
compression provided on November 5, 2019, and December 30, 2019.
You asked the Plan to waive the copayments for the application of vein wound compression. You say that you
were not aware that you would owe such a high charge 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 $250
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received the application of vein wound compression on November 5, 2019. The application of vein wound
compression is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed
amount of $206.65, which is less than the $250 copayment.
You received the application of vein wound compression on December 30, 2019. The application of vein
wound compression is considered an outpatient surgical procedure. Therefore, you are responsible to pay the
allowed amount of $157.66, which is less than the $250 copayment.
The total amount you owe is: $364.31.
You have been asked to pay the total copayment amount of $364.31 for the application of vein wound
compression. The application of vein wound compression falls within the outpatient surgery and other medical
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 for the application of vein wound compression provided on November
5, 2019, and December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProstatic Arterial Embolization (37243).You asked the Plan to pre-approvethis service. You say that prostatic arterial embolization is medically necessary for the enrollee.The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited international studies have demonstrated possible short-term safety and efficacy. Comparative studies to other methods such as transurethral resection of the prostate (TURP) are currently enrolling patients. The most recent American Urological Association (AUA) guidelines do not recommend this procedure outside of a clinical trial setting. As such, Prostatic Arterial Embolization is not medically reasonable and 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 this service have not been met.Therefore, we decided that the Plan does not have to pre-approveProstatic Arterial Embolization (37243).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73562 provided on June 15, 2020.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not separately 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. In this case, we have confirmed that code 73562
for the x-ray services has a bundled relationship with code 77073 and cannot be paid as billed. 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 for the x-ray services coded 73562 provided on
June 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided from July 16, 2020, through July 18, 2020.You asked the Plan to pay forthe orthoses and sleeves. You say that the claim should be paid.The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses and sleeves have not been met. The medical records submitted include an order form, exam notes, a letter explaining the need for the items billed and an invoice with the proof of delivery. However, per review of the member's claim history, there were no claims from the ordering/ referring physician within the last 6 months prior to the date of the service. Therefore, without a face-to-face encounter, the ordering physician couldn't gather the information associated with diagnosing, treating, or managing the clinical condition for which the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) were ordered.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1833) and suspension sleeves (L2397) provided from July 16, 2020, through July 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for physician services provided on February 4, 2020.
You asked the Plan to waive the cost share for the physician services. You say that you have dual benefits so you should not have a cost share. The Plan denied your request. The Plan says this claim will show a member responsibility on the Plan's Evidence of Benefits then the claim goes to Medicaid for a secondary processing.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible. This cost sharing is a contractual obligation that had not been met at the time the physician services was received on February 4, 2020. Therefore, we decided that the Plan does not have to waive the cost share for physician services provided on February 4, 2020.
Please note, this appeal is only for the physician services provided on February 4, 2020. Your appeal included other claims. Please contact the Plan with concerns about other claims.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe surgical services rendered on October 2, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 19499 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 19499 is unlisted procedure, breast.We find that CPT code 19499 is not supported in the medical record. Specifically, there is no documentation of a complete description of the unlisted code in the records. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan doesnot have to pay forthe surgical services rendered on October 2, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Ondansetron 4mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the
Plan's denial. The Plan denied your request. The Plan says this medication is not covered under the member's
contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Ondansetron 4mg tablet
medication.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided from May 31, 2019, to August 18, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in a home setting, which would be indicated by POS code 12. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided from May 31, 2019, to August 18, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefacial feminization surgery for the enrollee.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is considered cosmetic surgery.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  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 surgery. Our reviewer says that the requested surgery is not medically reasonable or necessary. Our reviewer found there is not sufficient medical documentation to fully evaluate the masculine nature of the enrollee, as photographs were not provided for review. Greater documentation is required to justify the procedures on a reconstructive basis.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 surgery have not been met.Therefore, we decided that the Plandoes not haveto pre-approvefacial feminization surgery for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approveMRI of the breast for the enrollee.You asked the Planto pre-approvethe MRI. You say that this is medically necessary.The Plandenied your request. The Plansaysthata mammogram, ultrasound and/or biopsy are supported for the initial evaluation of suspected breast pathology.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee has had persistent bloody discharge despite prior imaging with mammogram and ultrasound and biopsy with excision. MRI is considered when an occult malignancy is suspected and no findings on other modalities. The use of a breast MRI for this enrollee is reasonable and 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 the MRI have been met.Therefore, we decided that the Planhas to pre-approveMRI of the breast for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on April 9, 2020.
You asked the Plan to waive the copayment for emergency care. You say that the physician did nothing to treat
your pain and scolded you for going to the emergency room during a pandemic. 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 $120
copayment for emergency care.

You have been asked to pay a $120 copayment for emergency care. Emergency care 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 for emergency care provided on
April 9, 2020.

We note your complaint that the physician scolded you and did not treat your pain. Your complaint is a
grievance that must be answered by the health plan. Medicare does not permit us to make a decision about
these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer from a LTACH to admission to IRF care.
You asked the Plan to pre-approve IRF 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 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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to tolerate fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 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 transfer from a LTACH to admission to IRF care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the Rezum procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary.The Plan denied your request. The Plan says that the published scientific evidence does not support this procedure as safe, effective and/or having a reliable effect on health outcomes when compared to standard medical care.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 the procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the American Urological Association (AUA) considers transurethral destruction of prostate tissue; by radio-frequency generated water thermotherapy, also known as the Rezum procedure, to be a viable treatment of benign prostatic hyperplasia (BPH). Therefore, this procedure should be covered for reimbursement. The AUA does not consider this procedure to be investigational or experimental and, therefore, warrants coverage 

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 procedure have been met.Therefore, we decided that the Plan has to pre-approvethe Rezum procedure for the enrollee.