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

 We decided that the Plan has to waive the coinsurance for Eylea injections you received from November 6, 2020, to December 21, 2020.  You asked the Plan to waive the coinsurance for the Eylea injections. You say that you were advised by the Plan that you had met your out-of-pocket maximum prior to these services. The Plan denied your request. The Plan says that you were charged this coinsurance correctly.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan has not provided any evidence of how they calculated your out-of-pocket maximum for 2020. In fact, the only documents they provided in the case file they submitted related to your costs are the Explanations of Benefits from this period that explicitly state that you had met your out-of-pocket maximum.  They provided no evidence to the contrary in the case file. The burden is on the Plan to show why their assessment of coinsurance was correct, and they have failed to do so in this case. Therefore, we decided that the Plan has to waive the coinsurance for Eylea injections you received from November 6, 2020, to December 21, 2020.   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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiovascular risk assessment provided to the enrollee on December 21, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says while the Medicare allowed codes on this claim were paid, cardiovascular risk assessment testing for screening purposes is not covered by Medicare.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment provided to the enrollee on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an eye exam provided on June 15, 2021.  You asked the Plan to waive the copayment for an eye exam. You say that you disagree with the charges because you only wanted the name of a brand of eye drops. 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 $40 copayment for services for the diagnosis and treatment of diseases and injuries of the eye for vision care.   You have been asked to pay a $40 copayment for a diagnostic eye exam. A diagnostic eye exam falls within the vision 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 eye exam provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections. 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. The Plan 
denied your request. The Plan says the requirements for coverage have not been met. 
The Plan must follow Medicare rules. Medicare rules say that Facet Joint Interventions are considered 
medically reasonable and necessary for the diagnosis and treatment of chronic pain when the pain has been 
present for minimum of 3 months with documented failure to respond to noninvasive conservative management 
(as tolerated). 
We looked at the file and Medicare rules. The submitted medical records do not document the length of time 
the enrollee?s pain has been present. Based on this information, we decided that Medicare rules for coverage of 
facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet 
joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies coded A4550, A4556, A4557, A4649, A9999, 99072, S1015, and S8301 provided on April 30, 2021.

You asked the Plan to pay for the supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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.

We find that CPT codes A4550, A4556, A4557, A4649, A9999, 99072, S1015, and S8301 are not supported in the medical record. Specifically, codes A4550 and 99072 have a status indicator of "B". A status indicator of B means that payment for these services is always bundled into payment for other services not specified and no separate payment can be made. Codes A4556, A4557, and A4649 have a status indicator of "P". A status indicator of P means that payment for these services is always bundled into payment for other services not specified and no separate payment can be made. Code A9999 has a status indicator of "X". A status indicator of X means that payment for these services is always bundled into payment for other services not specified and no separate payment can be made. Codes S1015 and S8301 have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services.

Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the supplies coded A4550, A4556, A4557, A4649, A9999, 99072, S1015, and S8301 provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve block.  You asked the Plan to pre-approve genicular nerve block. You say that you have sharp shooting pain in the knee from different areas and this procedure is medically necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because medical literature shows there are mixed results in using genicular nerve blocks.  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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and radiofrequency ablations are considered experimental/investigational.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated vehicle (K0800).  You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says the submitted records do not show that the requirements for coverage have been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The limited submitted records show that the enrollee's condition can be improved by a manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met.  Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for specialist services and does not have to waive the coinsurance for a Medicare Part B drug provided on June 25, 2021.  You asked the Plan to waive the copayment for specialist services and does not have to waive the coinsurance for a Medicare Part B drug. You say that you have never been to the provider 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 $35 copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.  The medical records show that you received specialist services on June 25, 2021. Therefore, you are responsible to pay the $35 copayment.   The medical records show that you received a Medicare Part B drug on June 25, 2021. The total allowed amount is $732 and 20% of that is $146.40.   The total amount you owe is: $181.40.  You have been asked to pay the total amount of $181.40 for specialist services and a Medicare Part B drug. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. A Medicare 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 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 specialist services and does not have to waive the coinsurance for a Medicare Part B drug provided on June 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you feel that this is the best level of care for the enrollee. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 the enrollee continues to receive acute care services which have not been denied. The record does not indicate that the enrollee requires services that he is not currently receiving but which would be available at the LTACH 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on August 17, 2021.

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you disagree with the charges because the device was extremely uncomfortable. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for DME and related supplies. 

The enrollee received DME and related supplies on August 17, 2021. The total allowed amount is $778.22 and 20% of that is $155.64.

The enrollee has been asked to pay the total coinsurance amount of $155.64 for DME and related supplies. DME and related supplies fall within the DME and related supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prefabricated knee orthosis (L1845).

You asked the Plan to pre-approve the orthosis. You say that you have provided clinical documentation along with the physician order to assist with review of this request. The Plan denied your request. The Plan says the records do not support that the request is 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 the orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation indicates that there is no instability in the knee per the exam done by the provider and the enrollee has not had a recent injury or surgery to the knee. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve prefabricated knee orthosis (L1845).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for gene analysis provided on May 5, 2021.  You asked the Plan to waive the copayment for gene analysis. You say that the testing was necessary in order to diagnose your cancer. 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 20% coinsurance for molecular and predisposed genetic testing.  You received gene analysis on May 5, 2021, at an outpatient hospital facility. The total allowed amount is $267.12 and 20% of that is $53.42.  You have been asked to pay the total coinsurance amount of $53.42 for gene analysis. Gene analysis falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for gene analysis provided on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cefaly dual enhanced device (E1399).

You asked the Plan to pre-approve Cefaly dual enhanced device. You say that the Cefaly is an FDA approved treatment for migraines. The enrollee feels the Cefaly may help decrease the frequency of the migraines. The Plan denied your request. The Plan says this item is considered experimental and/or investigational. Medical studies have not proven that this device is helpful for the treatment of your enrollee's health problem.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cefaly dual enhanced device have not been met. Therefore, we decided that the Plan does not have to pre-approve Cefaly dual enhanced device (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision supply, accessory and/or service component of another vision code (V2797) provided on July 19, 2021.

You asked the Plan to pay for vision supply, accessory and/or service component of another vision code. The Plan denied your request. The Plan says that vision supply, accessory and/or service component of another vision code is not a covered vision benefit.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that vision supply, accessory and/or service component of another vision code is not a covered vision benefit. Therefore, we decided that the Plan does not have to pay for vision supply, accessory and/or service component of another vision code (V2797) provided on July 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intensive cardiac rehabilitation (G0422 and G0423) provided from June 28, 2021, to June 30, 2021, by an OON provider.  You asked the Plan to pay for the intensive cardiac rehabilitation. You say that these services were medically necessary and should be reconsidered for payment. The Plan denied your request. The Plan says these services were rendered by a non-network provider. The Plan also says that these services were not urgent or emergent, nor were they 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 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 the intensive cardiac rehabilitation (G0422 and G0423) provided from June 28, 2021, to June 30, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with an ES modifier provided on June 23, 2021.  You asked the Plan to pay for ambulance service, basic life support, emergency transport (A0429) with an ES modifier. You say that the claim was billed correctly. The Plan denied your request. The Plan says the claim was not submitted with the QL modifier.  The Plan must follow Medicare rules. Medicare rules say that providers report the A0428 (BLS) HCPCS code. Providers report modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, emergency transport (A0429) with an ES modifier have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport (A0429) with an ES modifier provided on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you are recommending LTACH for management of the enrollee's condition. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.  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 the enrollee continues to receive acute care services which have not been denied. The record does not indicate that the enrollee requires services that he is not currently receiving but which would be available at the LTACH. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on August 3, 2021.  You asked the Plan to pay for the bitewing x-rays (D0274). You say that the denial should be reconsidered. The Plan denied your request. The Plan says the service is not a covered benefit.  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.    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 the bitewing x-rays (D0274) provided on August 3, 2021.