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

We decided that the Plan does not have to waive the copayments for the hip injection and the x-ray provided on 
August 17, 2021.

You asked the Plan to waive the copayments for the hip injection and the x-ray. You say that in the past you 
have not had to pay such a high copayment. The Plan denied your request. The Plan says you have been asked 
to pay 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 $425 
copayment for each covered in-network surgery or surgical procedure performed as an outpatient at a hospital 
and a $50 copayment each covered in-network x-ray service. For this date of service, you have been asked to 
pay the allowed amount of the claim because this amount is less than the standard $425 copayment for the hip 
injection and the $50 copayment for the hip injection.

You have been asked to pay a $139.74 copayment for the hip injection and a $27.38 copayment for the x-ray. 
The hip injection falls within the "Outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers" benefit category. The x-ray 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 copayments for the hip injection and the x-ray provided on August 17, 
2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the pathology services provided on May 22, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee was seen for multiple exams on
the same date of service. The Plan denied your request. The Plan says that the documentation does not support
an additional study.
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 file shows that code 88305 was billed with one unit of service. The Plan states in their determination that
the code at issue was previously approved and paid. We looked at the file and the rules. The case file does not
include claim information that shows the service was previously paid for by the Plan. There is no additional
claim information provided to show that code 88305 was billed more than once on the date of service at issue.
There is no evidence provided that the claim line was a duplicate of another claim. The Plan has not made
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your
request. Therefore, we decided that the Plan has to pay for the pathology services provided on May 22, 2021.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Osteogenesis stimulator (E0748), provided on June 29, 2021.  You asked the Plan to waive the coinsurance for the Osteogenesis stimulator. You say that you did not know there would be a coinsurance. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for durable medical equipment (DME) and related supplies.   You have been asked to pay a 20% coinsurance for the Osteogenesis stimulator. This item 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 the Osteogenesis stimulator (E0748), provided on June 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a second office visit (procedure code 99214) provided to the enrollee on May 18, 2021.
You asked the Plan to pay for the visit. You say that this should be paid for. The Plan denied your request. The Plan says an excessive number of units was reported for an established patient office or outpatient visit when each unit requires distinct encounters.
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 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter." We find that a second unit of CPT code 99214 is not supported in the medical record. Specifically, the records do not show that two visits were provided on this date. If two visits had been provided, CPT 99214 as two units would not have been the correct code to use in this case.
There is a higher level code that would have been more appropriate. Based on this information, we decided that Medicare rules for coverage of the visit have not been met. Therefore, we decided that the Plan does not have to pay for a second office visit (procedure code 99214) provided to the enrollee on May 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a fluid circulating cold pad with pump (E0218), provided on July 30, 2021.

You asked the Plan to waive the copayment for a fluid circulating cold pad with pump. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a fluid circulating cold pad with pump have not been met. Therefore, we decided that the Plan does not have to waive the copayment for a fluid circulating cold pad with pump (E0218), provided on July 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the information submitted does not meet the plan's step therapy guidelines for coverage.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not contain documentation of trial and failure of Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Udenyca (pegfilgrastim-cbqv). The documentation does not support that Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), and Udenyca (pegfilgrastim-cbqv) 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 4, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for intermittent limb compression device.  You asked the Plan to pay for intermittent limb compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on June 14, 2021.  You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-covered.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing (0013M) provided on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for remote evaluations of single, dual, or multiple lead pacemaker system or implantable defibrillator system with technician review, support and distribution of results, up to 90 days (CPT code 93296) provided on May 26, 2020, and September 1, 2020.

You asked the Plan to waive the copayment for the services. You say that you were never told by the provider that there would be a cost-share for the services you received. The Plan denied your request. The Plan says the claims were 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 shows that you received remote evaluations of single, dual, or multiple lead pacemaker system or implantable defibrillator system with technician review, support and distribution of results, up to 90 days (CPT code 93296) on May 26, 2020, and September 1, 2020. You were asked to pay a $25 copayment for each date of service for the services. Your 2020 EOC states that enrollees must pay a $25 copayment for Medicare-covered non-radiological diagnostic services Examples include, but are not limited to EKG's, pulmonary function tests, home or lab-based sleep studies, and treadmill stress tests. 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 remote evaluations of single, dual, or multiple lead pacemaker system or implantable defibrillator system with technician review, support and distribution of results, up to 90 days (CPT code 93296) provided on May 26, 2020, and September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital visit provided on June 17, 2021, by an
OON provider.
You asked the Plan to pay for the outpatient hospital visit. You say that the service was medically necessary.
The Plan denied your request. The Plan says the provider is out-of-network
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. The
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the outpatient hospital visit provided on June 17, 2021, by an
OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the removal of a tunneled central venous access device provided on September 24, 2021.
You asked the Plan to waive the copayment for the removal of a tunneled central venous access device. You say that you do not feel that the services provided should warrant a copayment that high. 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 $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received the removal of a tunneled central venous access device, at an outpatient
hospital facility, on September 24, 2021. The removal of a tunneled central venous access device is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for the removal of a tunneled central venous access device. The removal of a tunneled central venous access device 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 the removal of a tunneled central venous access device provided on September 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay in full for the resin-based composite of two surfaces (D2331)
provided on September 1, 2021.
You asked the Plan to pay in full for the resin-based composite. You say that you informed the provider's office
that you had a $500.00 benefit and that you did not want to go over that amount. The Plan denied your request.
The Plan says your responsibility of $120.00 is correct.
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 Plan offers a combined benefit
maximum allowance of $500 per calendar year.
The record shows that you met the annual maximum benefit while processing this claim for the September 1, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay in full for the resin-based composite of two surfaces (D2331) provided on September 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation system and an additional light package/USB charger port (E2300, K0108) for a power wheelchair for the enrollee.  

You asked the Plan to pre-approve the items. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clear justification for these items.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    

The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and an additional light package/USB charger port (E2300, K0108) for a power wheelchair for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 4, 
2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that the doctor should not be 
penalized for the hospital staffs' failure to obtain prior authorization. The Plan denied your request. The Plan 
says no prior authorization was obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
records provided for review do not show that the service at issue was urgent or emergent. Therefore, we 
decided that the Plan does not have to pay for the subsequent nursing facility care provided on June 4, 2021, by 
an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional x-ray (74022) provided on July 26, 2021.  

You asked the Plan to pay for an additional x-ray. You say that this was performed. The Plan denied your request. The Plan says this was previously paid. 

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  

We find that an additional unit of CPT code 74022 is not supported in the medical record. The medical record only supports 1 unit of CPT code 74022. Based on this information, we decided that Medicare rules for coverage of an additional x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an additional x-ray (74022) provided on July 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 18, 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 services are not separately payable.  

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  

The provider submitted a claim for procedure codes 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound rendered on August 18, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of a skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says continuation of skilled nursing is not medically necessary and does not meet Medicare guidelines.

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 the services. Our reviewer says that the requested continuation of services is not medically reasonable or necessary. Our physician reviewer found you do not have documented skilled nursing needs. While the enrollee is noted to have developed sacral wounds, the care currently being provided for these wounds is unclear. You do not have documented skilled therapy needs. You appear to have reached a plateau in function following the below knee amputation (BKA) in October. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 

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 continuation of a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553) provided to the enrollee on July 28, 2021.

You asked the Plan to pay for the item. You say that the claim should be paid. The Plan denied your request. The Plan says the item is not covered.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

By definition, only three (3) units would be reported for a 90-day supply period. The reporting of more than one (1) unit of service per month of code K0553 will be denied as not reasonable and necessary. The monthly supply allowance for a continuous glucose monitor is not reportable before the expiration of the last monthly supply period since the overlapping period represent duplicate services. A different provider a prior claim for 3 month(s) of supplies on June 2, 2021. A review of the submitted documentation and related claim information indicates 3 month(s) of supplies were reported on date of service June 2, 2021, which overlap the current supply period being reported. Therefore, we decided that the Plan does not have to pay for supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service (CPT code K0553) provided to the enrollee on July 28, 2021.