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

We decided that the Plan does not have to waive the cost share for the infusion therapy services provided in an outpatient hospital facility from March 24, 2021 to April 7, 2021.
You asked the Plan to waive the cost share for the infusion therapy services provided in an outpatient hospital facility. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received infusion therapy services in an outpatient hospital setting on the dates of service at issue in this appeal.
The Plan says that the correct copayment has applied for the outpatient hospital services and the correct coinsurance has applied for the Part B drugs per your contract with the Plan.
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 $160 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges, and a 20% coinsurance for Medicare-covered Part B drugs. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received infusion therapy services provided in an outpatient hospital facility from March 24, 2021 to April 7, 2021. You have been asked to pay a $160 copayment for outpatient hospital facility services for each date of service. The outpatient hospital facility services fall within the Outpatient surgery and other medical services provided at hospital outpatient facilities benefit category. You have also been asked to pay a 20% coinsurance for the Part B infusion therapy services, totaling $123.90 for the March 24, 2021 date of service and $121.35 for the April 7, 2021 date of service. The Part B infusion therapy services fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the infusion therapy services provided in an outpatient hospital facility from March 24, 2021 to April 7, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found based on the documentation provided the enrollee does not require services at the
LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a debridement of muscle and/or fascia procedure (11043, 11046) performed on January 15, 2021.
You asked the Plan to waive the copayment for a debridement of muscle and/or fascia. You say that the services at issue are administered in the building next door from the hospital and that you do not want to continue paying hospital copayments when you are not going into the hospital. The Plan denied your request. The Plan says the correct copayment 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 $340 copayment for Medicare-covered surgical and non-surgical services in an outpatient department of a hospital or in an ambulatory surgical center.
You have been asked to pay a $340 copayment for a debridement of muscle and/or fascia. A debridement of muscle and/or fascia 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 copayment for a debridement of muscle and/or fascia procedure (11043, 11046) performed on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered for subluxation of the spine.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain documentation of subluxation of the spine. The requested treatment does not provide a significant expectation of recovery or improvement in function. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 13, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT
codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on April 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy pump (E2402) provided on December 30, 2020, to January 14, 2021.
You asked the Plan to waive the coinsurance for a negative pressure wound therapy pump. You say that you disagree with the charge at issue and would like to have it overturned. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare-covered durable medical equipment and related supplies. You have been asked to pay $393.60, or 20% of the Medicare-allowed charge of $1,968, for a negative
pressure wound therapy pump. A negative pressure wound therapy pump falls within the "Durable medical equipment (DME) and related 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 coinsurance for a negative pressure wound therapy pump (E2402) provided on December 30, 2020, to January 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan of the head or brain; without contrast material
(CPT code 70450) provided to the enrollee on March 8, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between 70450 and 70496. This PTP edit has a modifier indicator of 1, which indicates modifiers associated
with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.
Therefore, we decided that the Plan does not have to pay for the CT scan of the head or brain; without contrast
material (CPT code 70450) provided to the enrollee on March 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 2, 2021, to March 31, 2021.
You asked the Plan to pay for the SNF services. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did have skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Specifically, the file did not indicate that the enrollee required daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from March 2, 2021, to March 31, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network bone density and physician services provided
on February 9, 2021.
You asked the Plan to pay for these services. You say that these services should be covered by the Plan. The
Plan denied your request. The Plan says you did not have prior authorization for out of network care.
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 had network providers available who could have provided this service. The Plan did not pre-approve
this service. Therefore, we decided that the Plan does not have to pay for out of network bone density and
physician services provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a collection of blood specimen from a
completely implantable venous access device (CPT code 36591) provided on October 16, 2020.
You asked the Plan to waive the copayment for the service. You say that you are appealing your cost-share
responsibility for the services you received. The Plan denied your request. The Plan says the claim was
processed accordingly with your 2020 EOC 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).
Review of the file show that you received a collection of blood specimen from a completely implantable
venous access device (CPT code 36591) provided on October 16, 2020, at the outpatient department of the
hospital. The Medicare-allowed amount for the testing is less than the set $250 copayment; therefore, you have
been asked to pay the lesser amount of $110.73 for the testing. On the same day you received other laboratory
services (CPT code(s): 80053, 82378, 83735, 85025, and J1642) with a $0 copayment. Your total cost of
service is $110.73. Your 2020 EOC states that enrollees must pay a $250 copayment per visit for outpatient
surgery or procedure. This means that you have been asked to pay the correct amount based on your contract
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
Therefore, we decided that the Plan does not have to waive the copayment for a collection of blood specimen
from a completely implantable venous access device (CPT code 36591) provided on October 16, 2020
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no indication that the preferred agents would likely be less effective and/or
cause adverse effects.
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 the injection. Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has
not tried and failed the required drugs. The documentation does not support that Orthovisc and Monovisc
would likely be less effective and/or would likely have adverse effects for the enrollee in this case.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Gel-One injection for the enrollee
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel you received on March 18, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. The services were provided by a non-contract provider. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel you received on March 18, 2021
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services provided on May 4,
2021.
You asked the Plan to waive the copayment for the ambulance services. You say that ambulance transportation
should be included in your Plan policy. The Plan denied your request. The Plan says you were charged this cost
sharing 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 $200
copayment for each ambulance trip. You had 1 ambulance trip. The Plan charged you $200 for these services.
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 services provided on May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you exceed mobility and activities of daily living criteria for admission to SNF for skilled therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on March 3, 2021.
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 21. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation services represented by code 99153 provided on March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (80053, 84436, 36415, 84443) provided
on April 29, 2021.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the services were not emergent. There were network providers
available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the services 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 these services. Therefore, we decided
that the Plan does not have to pay for outpatient services (80053, 84436, 36415, 84443) provided on April 29,
2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 services provided by an out-of-network provider on April 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on February 24, 2021.
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 the enrollee did not have prior authorization for out of network care.
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 had network providers available
who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the
enrollee on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 purchased on May 6, 2021.
You asked the Plan to pay for these compression stockings. You say that the Plan should cover these stockings. The Plan denied your request. The Plan says compression stockings coded as A6530 are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6530 purchased on May 6, 2021.