Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided September 20, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that the x-rays were necessary. 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 bitewing x-rays once per plan year.  We looked at the file and Medicare rules. The Plan provided documentation showing that bitewing x-rays were previously covered on February 12, 2021. Based on this information, we decided that the Plan's frequency limit for coverage of the bitewing x-rays has been exceeded. Therefore, we decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274) provided September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for home visit services provided on July 26, 2021, by an OON provider.  You asked the Plan to pay for the home visit services. You say that services were provided to the enrollee. The Plan denied your request. The Plan says there was no prior authorization, and the provider is an out-of-network provider.   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 visit services provided on July 26, 2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an Emergency room CT scan provided on June 3, 2021.  You asked the Plan to waive the copayment for the Emergency room CT scan. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $225 copayment for Outpatient diagnostic tests and therapeutic services and supplies.      You have been asked to pay a $225 copayment for an Emergency room CT scan. Based on your contract with the Plan, when advanced imaging services are provided in an emergency room, you will only be charged the copayment for the imaging and not the visit itself. CT scans fall 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 copayment for an Emergency room CT scan provided on June 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Orthovisc.  You asked the Plan to pre-approve Orthovisc. You say that the drug is medically necessary. The Plan denied your request. The Plan says there is not documentation of at least three months of conservative therapy.  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 Orthovisc. Our reviewer says that this drug is not medically necessary. Our physician reviewer found the record does not indicate that conservative therapy was attempted and failed following the recent acute injury.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for specialist office visits provided on June 5, 2020, December 22, 2020, and March 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the specialist office visits. You say that you would like the Plan to reconsider authorizing the office visits. The Plan denied your request. The Plan says the office visit was with an out-of-network provider and there was no approved referral of authorization to see the out-of-network provider.  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 specialist office visits provided on June 5, 2020, December 22, 2020, and March 16, 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 echocardiogram provided on April 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an echocardiogram. You say that the enrollee showed proof of Medicare cards and insurance was not checked until the day after testing. The Plan denied your request. The Plan says the provider is a non-contracted provider and there was no pre-authorization for the services provided 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 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 an echocardiogram provided on April 16, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aflibercept (Eylea).    You asked the Plan to pre-approve Eylea. You say that your providers do not stock, supply, or administer Avastin due to it not being Food and Drug Administration approved. You also say that exudative age-related macular degeneration of the right eye with active choroidal neovascularization which the enrollee needs injections for is a medically necessary diagnosis. The Plan denied your request. The Plan says that there has been no trial of the Plan preferred medication, Avastin, and no medical contraindication to the Plan preferred medication.  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 Eylea. Our reviewer says that Eylea is not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, Avastin. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Aflibercept (Eylea).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia (J0897).  You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says this request does not meet the Plan's Part B coverage criteria for Prolia.    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 Prolia. Our reviewer says that Prolia (J0897) is not medically reasonable and necessary. Our physician reviewer found the enrollee has not tried and failed the required drug, Zoledronic Acid. Our reviewer also found that there is no indication that the Plan's required drug would likely be less effective and/or likely 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (47605, 76998) provided on April 22, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.  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 47605 is a column II code to column I code 47120. Additionally, code 76998 is a column II code to column I code 76705. 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 services (47605, 76998) provided on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on September 13, 2021.  You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the service at issue was 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 information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on September 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 23, 2021.  You asked the Plan to pay for a diagnostic or therapeutic injection. 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 information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 23, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from November 29, 2020 to December 14, 2020.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service has not been reported correctly.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the revenue code reported with Q5002 does not match the revenue code and date of service of the first reported home health service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from November 29, 2020 to December 14, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90834) provided on June 9, 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 clinical social worker 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 (90834) provided on June 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an elbow x-ray provided on October 26, 2021.   You asked the Plan to waive the copayment for the elbow x-ray. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 copayment for Outpatient diagnostic tests and therapeutic services and supplies.        You have been asked to pay a $20 copayment for an elbow x-ray. Elbow x-rays fall 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 copayment for an elbow x-ray provided on October 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on June 22, 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 June 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for Magnetoencephalography (MEG), recording and analysis provided on July 6, 2021.  You asked the Plan to pay for Magnetoencephalography (MEG), recording and analysis. The Plan denied your request. The Plan says the services were not authorized by network/primary care providers. Referral not authorized by attending physician.  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 Magnetoencephalography (MEG), recording and analysis provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Skil-Care Geri-Chair provided.  You asked the Plan to pre-approve the Skil-Care Geri-Chair. You say that you need this item. The Plan denied your request. The Plan says this item does not primarily serve a medical purpose.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the Skil-Care Geri-Chair provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection services rendered on June 17, 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 64447 (femoral nerve injection, anesthetic) and 01402 (anesthesia for open or surgical arthroscopic procedures on the knee joint). Code 64447 is a column II code with a modifier indicator of 1 when billed with column I code 01402. Code 64447 was not billed with an appropriate modifier to allow for separate payment. The -59 modifier is not supported as a separate and distinct procedure. Therefore, we decided that the Plan does not have to pay for the injection services rendered on June 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) scan of the head
(70544) provided on September 23, 2021.

You asked the Plan to pay for the MRA scan of the head. You say that you would like this claim reprocessed
for medical necessity. The Plan denied your request. The Plan says an appropriate modifier was not billed with
this claim.

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 70544
is a column II code to column I code 70551. 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 magnetic resonance angiography (MRA) scan of the head
(70544) provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for DME provided on August 2, 2021.  You asked the Plan to waive the copayment for DME. You say that you disagree with the charges because you were in the hospital when you received the device. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies.   You received DME on August 2, 2021. The record shows that the DME you received is not included in the hospital stay and is subject to separate cost-sharing charges. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $1,456.35 and 20% of that is $291.27.  You have been asked to pay the total coinsurance amount of $291.27 for DME. DME falls within the 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 copayment for DME provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for placement of occlusive device (G0269) provided on August 4, 2021.  You asked the Plan to pay for placement of occlusive device. You say that the medical records support the claim as billed. The Plan denied your request. The Plan says this code is not paid separately.  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 G0269 is placement of occlusive device into either a venous or arterial access site, post surgical or interventional procedure (e.g., angioseal plug, vascular plug).  We looked at the file and Medicare rules. In this case, this code has a Status Code of "B" under the Physician Fee Schedule which indicates that it is a Bundled Code. Payment for covered services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of placement of occlusive device have not been met. Therefore, we decided that the Plan does not have to pay for placement of occlusive device (G0269) provided on August 4, 2021.