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

 We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 25, 2021.  You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says prior authorization was not requested.  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 subsequent nursing facility care provided on May 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, emergency transport (A0429) provided May 13, 2021.  You asked the Plan to waive the copayment for the emergency ambulance transport. You say that you believe the service was billed incorrectly. The Plan denied your request. The Plan says the copayment 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 $250 copayment for each one-way Medicare-covered ground ambulance trip.   You have been asked to pay a $250 copayment for the emergency ambulance transport. The emergency ambulance transport falls within the Ambulance 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 the ambulance service, basic life support, emergency transport (A0429) provided May 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation (A0422) provided on June 3, 2021.  You asked the Plan to pay for ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation. The Plan denied your request. The Plan says suppliers are paid at a base rate to include supplies with mileage allowed separately.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, is included in the fee schedule payment.  We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation (A0422) provided on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for eyewear provided on June 28, 2021.  You asked the Plan to pay an additional amount for eyewear. The Plan denied your request. The Plan says your benefit only covers up to the maximum allowed amount of the $150 eyewear allowance.  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 the Plan has paid the maximum allowed amount of $150 for the eyewear. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided on June 28, 2021.
Appeal type: Surgery
Decision: Partially Favorable

 We decided that the Plan has to waive any amount in excess of your 20% coinsurance for the ferumoxytol injection. We decided that the Plan does not have to your 20% coinsurance for the ferumoxytol injection.   You asked the Plan to waive your 20% coinsurance for the ferumoxytol injection. You say that you would like reconsideration because you have had these services in the past and the cost was not as high. The Plan says that the cost sharing that has been applied is appropriate.  We decided that the Plan has to waive any amount in excess of your 20% for the ferumoxytol injection.   The Plan follows Medicare rules. Medicare rules say that a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). The Health Plan contract says that you must pay 20% coinsurance for Medicare Part B Prescription Drugs.  The service at issue is a Medicare Part B Drug. You have been asked to pay more than 20% of the allowed amount for the Prescription Drug. Therefore, we decided that the Plan has to waive any amount in excess of your 20% coinsurance for the ferumoxytol injection.   We also decided that the Plan does not have to waive the 20% coinsurance for the ferumoxytol injection.  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 the ferumoxytol injection. Therefore, we decided that the Plan does not have to waive the 20% coinsurance for the ferumoxytol injection.  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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Synvisc.  You asked the Plan to pre-approve Synvisc. You say that the enrollee has very advanced degenerative changes in both knees. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Synvisc.  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 Synvisc. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Synvisc. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The documentation does not support that these drugs would likely be less effective and/or have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Synvisc.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you recently had a knee replacement, you live alone, and you have no one to help you while you are recovering. You state that your knee is very painful, and you have trouble walking. The Plan denied your request. The Plan says the services are custodial in nature and not covered.  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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of discharge from the hospital you had stabilized medically. You did not require any skilled nursing or rehabilitation services on a daily basis at an inpatient level of care. You were not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. You did not have any parental medication, complex wound care or nutrition given via a feeding tube. you were medically stable without any acute exacerbations of chronic medical problems. Your physical function was at or near your baseline and you could have received further services at a lower level of care. Admission to the nursing facility at a skilled level of care for inpatient skilled services is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the skin growth removal provided on June 28, 2021.

You asked the Plan to waive the deductible for the skin growth removal. You say that this service was not surgical. You say that you think it is unfair. The Plan denied your request. The Plan says you have been charged the correct cost share amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to outpatient surgery. 

Skin growth removal is considered a surgical service. The item or service you asked the Plan to pay the deductible for falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the skin growth removal was received on June 28, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the skin growth removal provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure) (77063) provided on July 8, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the screening digital breast tomosynthesis. You say that you were unaware that the claim required any prior notification as a Medicare plan. Please review your supporting documents and reconsider your claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 the screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) screening digital breast tomosynthesis, bilateral (list separately in addition to code for primary procedure) (77063) provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient visit for the evaluation and management of a patient (99202-57) provided on May 6, 2021.  You asked the Plan to pay for the outpatient evaluation and management visit. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says CPT code 99202 was not billed with the required modifier.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that physicians providing a nonchemotherapy drug infusion service and evaluation and management services on the same day must bill in accordance with SS30.6.6 using modifier 25.  We find that CPT code 99202-57 is not supported in the record. Specifically, this claim was billed with a CPT code for a nonchemotherapy drug infusion service and an evaluation and management service. CPT code 99202 was not billed with the required modifier. Based on this information, we decided that Medicare rules for coverage of the outpatient evaluation and management visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient visit for the evaluation and management of a patient (99202-57) provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Laparoscopy, surgical, colpopexy (suspension of vaginal apex) (57425) Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) (58661) provided April 6, 2021.  You asked the Plan to pay for the surgical procedure. You say that both the primary surgeon and the facility are in network and CPT 57425, 58661 is payable to the assistant surgeon, you are requesting the assistant surgeon's claim to be processed at the in-network rate. The Plan denied your request. The Plan says the prescribing/ordering provider is not eligible to prescribe/order the service billed. Registered nurse first assistants are not recognized as physicians per Medicare guidelines.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for Laparoscopy, surgical, colpopexy (suspension of vaginal apex) (57425) Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) (58661) provided April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can be safely treated at the skilled nursing facility level of care.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical management of traumatic subdural hematomas. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for the unspecified preventive service (D1999), sales tax (D9985), prophylaxis (D1110), and comprehensive oral evaluation (D0150) provided on June 1, 2021.  You asked the Plan to reimburse you for the dental services. You say that services you received from this provider in March 2021 were paid. You say that had you known the provider had opted out of Medicare, you would have selected a new dentist. You also say you were advised you should be reimbursed for your cleaning. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services rendered to a dentist that has opted out of Medicare.  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, dental services performed by a dentist that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the unspecified preventive service (D1999), sales tax (D9985), prophylaxis (D1110), and comprehensive oral evaluation (D0150) provided on June 1, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 7, 2021.  You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says the services are a non-covered benefit.   The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.      The ambulance company did not provide transport services on April 7, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on July 21, 2021.  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 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 must 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 medical services provided to the enrollee on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (CPT code 99153) provided to the enrollee on May 25, 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 the services are 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.  Claim denial was applied per CMS regulations, CPT code 99153 has a professional component (PC)/technical component (TC) indicator of 3 per the April 2021 National Physician Fee Schedule Relative Value File, we find that Medicare rule for payment of this claim has not been met. 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 moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (CPT code 99153) provided to the enrollee on May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient rehabilitation services provided on September 24, 2021, through October 8, 2021.  You asked the Plan to pay for the inpatient rehabilitation services. You say that the service should be covered. 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 $350 copayment each day one through five. for inpatient hospital care.   You have been asked to pay a $350 copayment each day one through five. for the inpatient rehabilitation services. This service falls within the inpatient hospital 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 pay for the inpatient rehabilitation services provided on September 24, 2021, through October 8, 2021.