Persius/hicric huggingface dataset:
Appeal type: Hospice
Decision: Partially Favorable

 We decided that the Plan has to pay for the home health services provided from August 1, 2021, to August 11, 2021. We decided that the Plan does not have to pay for the home health services provided from July 13, 2021, to July 31, 2021.   You asked the Plan to pay for the home health services provided from August 1, 2021, to August 11, 2021. You say that the enrollee was not enrolled in hospice on the date of service in this case. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.  We decided that the Plan has to pay for the home health services provided from August 1, 2021, to August 11, 2021.   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. Specifically, the file shows that the enrollee revoked their hospice election in July 2021. Services received after the last day of the month following a hospice revocation are eligible for coverage under their Medicare Part B coverage. Therefore, we decided that the Plan has to pay for the home health services provided from August 1, 2021, to August 11, 2021.   We also decided that the Plan does not have to pay for the home health services provided from July 13, 2021, to July 31, 2021.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on July 8, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the home health services provided from July 13, 2021, to July 31, 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by an out-of-network (OON) provider on September 29, 2021 and October 14, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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.  You are not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by an out-of-network (OON) provider on September 29, 2021 and October 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested drug is being used for an off-label and unsupported condition.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Aduhelm. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment or mild dementia stage of disease. However, the magnetic resonance imaging in this case suggests the presence of cerebrovascular disease, which is evidence of a mixed etiology for the enrollee's symptoms. It has not been shown that Aduhelm is at least as beneficial as existing, available, and medically appropriate alternatives for this enrollee. At this time, it is not clear that Aduhelm is reasonably expected to be safe and effective 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Aduhelm.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on August 25, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.   We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar epidural injection services.  You asked the Plan to pre-approve lumbar epidural injection services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the benefit for epidural steroid injections has been exhausted at this time.  The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period.  We looked at the file and Medicare rules. In this case, the record illustrates that the enrollee has already received 4 epidural steroid injections within the last twelve months. Based on this information, we decided that Medicare rules for coverage of lumbar epidural injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural injection services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 20, 2021.  You asked the Plan to pay for the limited oral exam. You say that you disagree with the billing of this service. The Plan denied your request. The Plan says you have exceeded the frequency limit for this service.  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. The Plan covers the limited oral exam twice per calendar year.   We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam (D0150) was previously covered on April 7, 2021, and a periodic exam (D0120) was covered on July 6, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for pathology services (88305, 88312) provided on October 20, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for pathology services. You say that the doctor's office failed to send in a preauthorization form for approval. You also say that the patient does not go there to your laboratory, so he/she is not using out-of-network benefits as his/her participating doctor sends you the specimens to process. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in a participating facility. The Plan also says that they 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 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 pathology services (88305, 88312) provided on October 20, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided September 3, 2021.  You asked the Plan to pay for the non-emergency ambulance service. You say that the enrollee required ambulance transport. The Plan denied your request. The Plan says information provided at the time of the appeal does not support medical necessity for ambulance transport.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the non-emergency ambulance service. Our reviewer says that the non-emergency ambulance transport on September 3, 2021, was not medically necessary. Our physician reviewer found that the enrollee could have been safely transported by another type of motor vehicle, possibly a van transport vehicle. The review has determined that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on September 3, 2021.   The documentation did not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on September 3, 2021. The documentation did not support that the ambulance transport on September 3, 2021, was medically reasonable and necessary 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 the non-emergency ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage (A0425) provided September 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for hearing aids provided on August 1, 2021.  You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says there is no coverage if hearing aids, or related services are received from a provider not part of the Plan's hearing aid vendor's network. The hearing benefit is not covered if the services are not registered in advanced.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered from a provider in the Plan's hearing vendor's network.     We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered and provided by the Plan's hearing vendor's network. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing aids provided on August 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for excision procedures on the hand and fingers (26250, 14040, 25077) provided on February 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for excision procedures on the hand and fingers. You say that an authorization was issued for this provider, and it was issued with the incorrect tax ID for the ambulatory center. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they 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 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 excision procedures on the hand and fingers (26250, 14040, 25077) provided on February 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit provided on October 4, 2021.  You asked the Plan to waive the copayment for the PCP office visit. You say that you were informed by the staff that the visit was for an annual physical. The Plan denied your request. The Plan says you have been charged 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 $10 copayment for each visit with your PCP.   The file shows that the visit was a follow-up visit for diabetes. Therefore, you have been asked to pay a $10 copayment for the PCP office visit.  The PCP office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a primary care physician (PCP) office visit provided on October 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a LifeVest (K0606) provided on February 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a LifeVest. You say that due to the processes of the Plan, this provider could not reasonably have known a prior authorization was required or secured a prior authorization. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved in advanced.  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 a LifeVest (K0606) provided on February 25, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services (S9122), ambulance mileage (A0888), and unlisted special service (99199) provided from May 1, 2021, to July 31, 2021.  You asked the Plan to pay for the home health services. You say that the services are medically necessary. The Plan denied your request. The Plan says the provider in this case is not a certified Medicare provider. The Plan also says that payment cannot be made to a provider that is not certified for Medicare.    The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services (S9122), ambulance mileage (A0888), and unlisted special service (99199) provided from May 1, 2021, to July 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 13, 2021.

You asked the Plan to waive the copayment for arthrocentesis. You say that you should only owe a $40 copayment. 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 $290 copayment for outpatient surgery, including services provided at hospital outpatient facilities. 

You received arthrocentesis at an outpatient hospital facility on October 13, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $290 copayment.

You have been asked to pay a $290 copayment for arthrocentesis. Arthrocentesis 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 arthrocentesis provided on October 13, 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.  You asked the Plan to pre-approve IRF care. You say that the enrollee meets criteria for IRF, and care cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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. Our physician reviewer found at the enrollee's current level of function, the enrollee does not need intensive therapies consisting of at least 3 hours of therapy per day for at least 5 days per week with a multidisciplinary approach to daily therapy. The enrollee is unlikely to make significant functional progress in a reasonable period of time in an IRF. While the enrollee may benefit from physical and/or occupational therapy, rehabilitation needs can be met safely in an alternate lower intensity setting such as a skilled nursing 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 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic (G0463, 85610) provided on July 20, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a hospital outpatient clinic. You say that it is your opinion that the services provided were medically reasonable and necessary for the treatment of the patient's condition. The Plan denied your request. The Plan says this provider is a non-contracted provider with the Plan and there is no record of a request for an authorization prior to offering the services which were neither urgent nor emergent in nature. The Plan also says that there is no referral from a participating provider for this Plan.

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 a hospital outpatient clinic (G0463, 85610) provided on July 20, 2021, by an out-of-network (OON) provider.