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

 We decided that the Plan does not have to pay for a microslide consultation (88321) provided on June 7, 2021.  You asked the Plan to pay for microslide consultation 88321. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this exceeds the medically unlikely edit (MUE) value for this code.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 7 units of this code, exceeding the MUE. The Plan approved payment for 1 unit. Based on this information, we decided that Medicare rules for coverage of microslide consultation 88321 have not been met. Therefore, we decided that the Plan does not have to pay for a microslide consultation (88321) provided on June 7, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on
December 3, 2020.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on
December 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on July 15, 2021.
You asked the Plan to pay for physical therapy services. The Plan denied your request. 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. We have also determined that these services are 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 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 physical therapy services provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the intravenous infusion services provided in an outpatient hospital facility on August 5, 2021.
You asked the Plan to waive the copayment for the intravenous infusion 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 facility. The Plan says that the correct copayment has applied 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 $245
copayment for services provided in an outpatient hospital facility.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received intravenous
infusion services in an outpatient hospital facility on August 5, 2021. You have been asked to pay a $189.19
copayment for the intravenous infusion services provided in an outpatient hospital facility, which is less than
the contracted $245 copayment amount. The intravenous infusion services provided in an outpatient hospital
facility falls within the Hospital Outpatient Facilities 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 intravenous infusion services provided in an outpatient hospital facility on August 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on February 26, 2021 to March 24, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 home health services provided on February 26, 2021 to March 24, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound services (76705) provided on August 9, 2021.  You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed and approved for payment based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required by Medicare rules.  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 76705 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. 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 ultrasound services (76705) provided on August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a therapeutic continuous glucose monitor (CGM) provided on July 29, 2021.  You asked the Plan to waive the coinsurance for therapeutic CGM. You say that you were told you had met your maximum out-of-pocket amount. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.  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 in-network therapeutic CGM. At the time this claim was processed, $4,944.86 of the $5,300 maximum out-of-pocket amount had been met. The allowed amount of the claim is $259.72, resulting in a coinsurance amount of $51.94.  You have been asked to pay 20% coinsurance for therapeutic CGM. Therapeutic CGM 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 therapeutic continuous glucose monitor (CGM) provided on July 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic (CPT code 96401) provided to the enrollee on July 9, 2021.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says there is a more appropriate code to describe the services provided.  
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 asked our coder 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 service. 
Our reviewer found the medical records provided do not include sufficient documentation to validate that CPT code 96401 was provided on July 9, 2021, therefore, this service cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic (CPT code 96401) provided to the enrollee on July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded as 99239 provided on March 4, 2021.  
You asked the Plan to pay for the hospital discharge day management services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation submitted does not support the services 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.  
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes.  We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation provided does not support that more than 30 minutes were spent performing the hospital discharge services. There is a more appropriate to support the services documented in the medical documentation. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded as 99239 provided on March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 16, 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. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. 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 CT scan, head or brain; without contrast material (CPT code 70450) provided to the enrollee on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the glucagon injection provided on July 19, 2021.  You asked the Plan to waive the coinsurance for the glucagon injection. You say that you did not receive an injection of medication and should not have a bill for $35.49. 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 20% coinsurance for Medicare covered Part B drugs and other Medicare covered items.     
You have been asked to pay $35.49 which is 20% of the allowed amount for the glucagon injection. The allowed amount is $177.45. ($177.45x20% = $35.49). The glucagon injection falls within the "Medicare Part B prescription drugs" benefit category. The medical record shows intravenous glucagon was administered during the magnetic resonance imaging (MRI).  
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 glucagon injection provided on July 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81265, 81266) provided to the enrollee on March 10, 2021.  You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan denied your request. The Plan says medical records were required and there are no records submitted which mention the test or give rationale for being ordered. 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 laboratory services have not been met. Medical records were not provided to verify if the services were necessary and met Medicare criteria. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81265, 81266) provided to the enrollee on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive pharmacogenetic testing provided on January 20, 2021.  You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must be submitted for the panel.  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 looked at the file and the rules. We find that the panel testing provided was billed with multiple codes. If a single procedure is performed, only one code with one unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenetic testing provided on January 20, 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 you have not had enough therapy and are not at your prior level of function. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for coverage and no longer requires daily skilled services. The Plan says that the continuation of SNF care is not medically necessary.  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 the enrollee received oral medications, had stable vital signs, and was treated for conjunctivitis. The enrollee received physical therapy, occupational therapy, and speech therapy. The enrollee was at a minimal to maximal assist level for functional mobility, including gait to 65 feet. The enrollee required varying assist with activities of daily living. The enrollee tolerated a mechanical soft diet and thin liquids. There are no identifiable daily skilled therapy service needs. There are no identifiable daily skilled nursing service needs. The enrollee does not meet the severity of illness or intensity of service criteria for 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the psychotherapy visits provided on August 2, 2021, and August 30, 2021.   You asked the Plan to waive the copayments for the psychotherapy visits. You say that you have never paid a copayment before, and you cannot afford it. 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 $40 copayment for each Medicare-covered individual or group visit.   
You have been asked to pay a $40 copayment for each of the psychotherapy visits. The psychotherapy visits fall within the "Outpatient mental health 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 copayments for the psychotherapy visits provided on August 2, 2021, and August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).  You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.    
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Eylea.  
You asked the Plan to pre-approve Eylea. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of bevacizumab (such as Avastin) before it will approve Eylea.  
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. 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.  
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 submitted any medical records or documented attempts to obtain medical records related to this request. Without medical records, we cannot determine whether the enrollee has tried and failed - or otherwise has a contraindication to - the Plan's preferred drug of bevacizumab. Therefore, the Plan has not shown that its decision to deny authorization for step therapy is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pre-approve use of Eylea.    
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 the thyroid testing provided on June 23, 2021.  
You asked the Plan to pay for the testing services. You say that each code has a diagnosis to meet medical necessity. The Plan denied your request. The Plan says the service is not covered as a screening tool.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   
In this case, the CPT Code Manual definition of code 84443 is thyroid stimulating hormone (TSH). We find that CPT code 84443 is not supported in the medical record. 
Specifically, testing without signs or symptoms are not covered. Medicare does not cover this testing for screening purposes. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the thyroid testing provided on June 23, 2021.