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

 We decided that the Plan does not have to pre-approve an epidural injection at additional levels (64484).  You asked the Plan to pre-approve an epidural injection at additional levels. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 an epidural injection at additional levels. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not meet Medicare coverage criteria for epidural injections for an additional level.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural injection at additional levels have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection at additional levels (64484).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on July 19, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON lab services. You say that this patient is in a nursing home and these labs were ordered by the attending physician who is not the member's primary care physician. You said that the your hospital has no control over this. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered. The Plan also said that there was no network referring provider on the claim.

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 provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab services provided on July 19, 2021, by an out-of-network (OON) provider.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as a skilled nursing facility or an assisted living facility with services.  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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage, per statute mile (A0425) provided  June 30, 2021.  You asked the Plan to waive the copayment for the non-emergency transport and ground mileage. You say that you were told the hospital would take care of the transportation. 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 Medicare-covered ground ambulance transport (one-way).  You have been asked to pay a $250 copayment for the non-emergency transport and ground mileage. The non-emergency transport and ground mileage 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, advanced life support, non-emergency transport, level 1 (A0426) and ground mileage, per statute mile (A0425) provided June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from June 11, 2021, to June 24, 2021.  You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.  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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there were no identifiable skilled nursing service needs. There were no identifiable skilled therapy service needs. The enrollee did not require skilled nursing or therapy services on a daily basis. The enrollee's medical condition did not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from June 11, 2021, to June 24, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency room (ER) services you received from February 26, 2021, to February 28, 2021.

You asked the Plan to waive the copayment for the ER services. You say that you were released in the evening and you could not find transportation home. You stated that they could not admit you because they could not find anything wrong with you. You stated that you cannot afford this bill. The Plan denied your request. The Plan says you were charged this copayment 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 $120 copayment per visit for emergency room services.

You have been asked to pay a $120 copayment per visit for the ER services. This copayment applies regardless of the reason for the ER visit. 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 emergency room (ER) services you received from February 26, 2021, to February 28, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the computed tomography (CT) of the head or brain (70450) provided on March 14, 2021.  You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says that procedures 70450 and 70496 include imaging of the head or brain and procedure 70496 is a more comprehensive procedure that includes imaging procedures 70450 as well as additional components.  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 Plan has denied CPT code 70450 as being inclusive to CPT code 70496. The Plan has not forwarded any evidence that CPT code 70496 was billed or or paid for the same date of service. The Plan has not forwarded any evidence that CPT code 70450 is inclusive to any service billed for the same date of service. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the computed tomography (CT) of the head or brain (70450) provided on March 14, 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 home infusion services (99601) provided April 14, 2021.  You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not eligible for Medicare payment.  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 find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, this code has a status of "I" and is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (99601) provided April 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for injectable drugs you received on July 21, 2021.  You asked the Plan to waive the coinsurance for the injectable drugs. You say that you believe you had already met your out-of-pocket maximum for the year, so you shouldn't owe this cost sharing. The Plan denied your request. The Plan says you had not yet met your out-of-pocket maximum at the time that these claims were processed. You had only met $6558.30, and your out-of-pocket maximum is $6700.  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 Part B drugs.   You have been asked to pay 20% coinsurance for the injectable drugs. The injectable drugs fall within the Medicare Part B drugs benefit category. The Plan has provided a breakdown of all of the charges you have paid for the year.  This breakdown confirms that you had not met your out-of-pocket maximum at the time that of these services. 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 injectable drugs you received on July 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve block services.  You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative treatment. The Plan denied your request. The Plan says there is insufficient evidence to assess the impact on health outcomes for the enrollee.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has chronic Left knee pain. He has tried non-steroidal anti-inflammatory drugs and physical therapy. He currently takes Naproxen and Norco for pain. He has a functioning spinal cord stimulator. The requested procedure is experimental/investigational and is the subject of ongoing clinical trials.  Therefore, the request is considered not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for cardiovascular risk assessment panel provided to the enrollee on August 31, 2020.  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 Medicare coverage criteria were not met.   The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pay for these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is whether the requested genetic testing was medically reasonable and necessary. The test is described by the manufacturer, Redwood Lab Services, as a genetic-based cardiovascular risk factor screening test in which 62 genes are assessed using genomic DNA extracted from buccal swabs. The test has not been approved by the FDA. It assesses the presence of pathogenic or likely pathogenic variants in genes known to be associated with increased cardiac risk. It is not a diagnostic test. There is no evidence to support its role in this patient's clinical management. In summary, the requested testing is not considered reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment panel provided to the enrollee on August 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).  You asked the Plan to pre-approve a Group 1 standard power operated vehicle. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for power mobility devices have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file does not show that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea.  You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under Medicare Part B.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Eylea.   Benefits for Eylea 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99135 billed for date of service June 9, 2021.  You asked the Plan to pay for procedure code 99135. You say that you believe these services should be paid as billed. The Plan denied your request. The Plan says this code is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of 'B' are never separately payable.  You billed code 99153.  This code has a status indicator of 'B', so no separate payment is allowable for this code. Therefore, we decided that the Plan does not have to pay for procedure code 99135 billed for date of service June 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided the Plan does not have to waive the $15 copayment for the swallow test provided on July 12, 2021.  You asked the Plan to waive the $15 copayment for a swallow test. You say that the specialist stated they would cover the cost of the office visit. The Plan denied your request. The Plan says this copayment was charged based on the services rendered and the claim submitted by the provider.   The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). The contract with the Plan clearly says that enrollees must pay a $15 copayment for outpatient diagnostic services, such as a swallow test. This type of testing is charged separately from the office copayment. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $15 copayment for a swallow test provided on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services billed with code 99153 for date of service February 23, 2021.

You asked the Plan to pay for code 99153. You say that you have attached medical records to this claim for reconsideration. The Plan denied your request. The Plan says because this code was billed with a facility place of service, this code is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that denials will occur codes with a Professional Component/Technical Component (PC/TC) indicator of '3' when performed in a facility place of service (POS) setting. CMS assigned code 99153 a PC/TC indicator OF '3'. However, you have billed this service with a Place of Service of '22', which is an outpatient hospital facility. This means that this service is not separately payable when performed by a physician in a facility setting because the facility has staff on hand to perform this service.

We looked at the file and Medicare rules. Therefore, we decided that the Plan does not have to pay for the moderate sedation services billed with code 99153 for date of service February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on June 3, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON lab services. You say that your lab is the sole provider of this service, so this should be covered. The Plan denied your request. The Plan says neither the order provider nor the provider of the lab services is a network provider with the Plan.  The Plan says that unauthorized, non-plan care is not covered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. Although your lab may be the sole provider of this service, that does not remove the provider's obligation to follow Plan authorization rules. 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 lab services provided on June 3, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for a computed tomography, head or brain (70450) provided on September 28, 2020.  You asked the Plan to pay for a computed tomography, head or brain (70450). The Plan denied your request. The Plan says despite multiple requests by the Plan, the provider has not submitted any clinical records to support the medical necessity of the services.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.     We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of a computed tomography, head or brain (70450) have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography, head or brain (70450) provided on September 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the upper partial denture (D5225).  You asked the Plan to pre-approve the upper partial denture (D5225). The Plan denied your request. The Plan says you met the benefit maximum of 1 complete or partial denture every 5 years.  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, you also have a maximum benefit of one of D5110-D5226, D5282, D5283, or D5863-D5866 every 60 months. The Plan paid for the upper partial denture (D5225) provided on November 10, 2017, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial denture (D5225).