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

We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) and anesthesia service (64425) provided on July 9, 2020.
You asked the Plan to pay for the ultrasonic guidance for needle placement and anesthesia service. You say that you are aware of the $350 copayment, but that you were double billed for the same service. The Plan denied your request. The Plan says you were only billed the $350 copayment. The additional claims were billed with $0 member responsibility.
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 for outpatient hospital services.
You have been asked to pay $350 for the ultrasonic guidance for needle placement and anesthesia service. Ultrasonic guidance for needle placement and anesthesia service falls within the outpatient hospital 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 pay for ultrasonic guidance for needle placement (76942) and anesthesia service (64425) provided on July 9, 2020.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gemcitabine, Cisplatin, Bevacizumab BVZR, Dexamethasone Sodium Phosphate, Famotidine, and Diphenhydramine.
You asked the Plan to pre-approve Gemcitabine, Cisplatin, Bevacizumab BVZR, Dexamethasone Sodium Phosphate, Famotidine, and Diphenhydramine. You say that this drug regimen is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested drugs are not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Gemcitabine, Cisplatin, Bevacizumab BVZR, Dexamethasone Sodium Phosphate, Famotidine, and Diphenhydramine. Our reviewer says that the requested drug regimen is not medically reasonable and necessary. Our physician reviewer found the enrollee is an 80-year-old diagnosed with multiple myeloma in 2009. In 2018 the enrollee was then diagnosed with non-small cell lung cancer. In this case, multiple agent therapy is not FDA-approved for the enrollee's diagnosis as it is not indicated for progression of the disease. In addition, the use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in an approved medical journal. The cited article in this case is for 1st line therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gemcitabine, Cisplatin, Bevacizumab BVZR, Dexamethasone Sodium Phosphate, Famotidine, and Diphenhydramine have not been met. Therefore, we decided that the Plan does not have to pre-approve Gemcitabine, Cisplatin, Bevacizumab BVZR, Dexamethasone Sodium Phosphate, Famotidine, and Diphenhydramine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and
services provided from January 18, 2021, to January 27, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that you disagree with the cost sharing
assessed. The Plan denied your request. The Plan says the claim was processed correctly, and the
copayment was assessed in accordance with your contract.
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 $403
copayment for each of the first five days of an inpatient hospital admission. There is a $0 copayment for the
sixth day and beyond.
You have been asked to pay a $2,015 copayment for inpatient hospital stay, which lasted longer than five days.
($403 x 5 days = $2,015). 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 inpatient hospital
admission and services provided from January 18, 2021, to January 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 32 additional home health physical therapy services.
You asked the Plan to pre-approve the 32 additional home health physical therapy services. You say that the
records provided support the need for the requested home health physical therapy visits. The Plan denied your
request. The Plan says the requested home health physical therapy services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 32 additional home health physical
therapy services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer
found the enrollee underwent right knee replacement and receiving physical therapy with no other pertinent
functional assessment or progress documentation in the records to justify the request for additional therapies. The records do not show that skilled nursing services or skilled therapy services are required to effectively
provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a
maintenance program to maintain the patient's condition and/or prevent deterioration. Home health aide
services from a skilled professional staff are not reasonable and necessary to treat the enrollee's illness or
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 the 32 additional home health physical therapy services have not been met.
Therefore, we decided that the Plan does not have to pre-approve 32 additional home health physical therapy
services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient bronchoscopy procedure.

You asked the Plan to pre-approve inpatient bronchoscopy procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 inpatient bronchoscopy procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found placement of endobronchial valves (EBV) is considered not medically necessary because patient selection criteria are not met. Patient selection criteria, based in patients in the clinical trials, include forced expiratory volume (FEV1) between 15 and 45% predicted, and residual volume (RV) at least 175% predicted. This enrollee's FEV1 is 50% predicted and RV is 167% predicted. Therefore, this enrollee may not get the same benefits from the procedure as those reported in the clinical trials. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient bronchoscopy procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient bronchoscopy procedure.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the powered air mattress overlay (E0372), provided on May 6, 2021.
You asked the Plan to pay for the powered air mattress overlay. You say that the item is medically necessary. The Plan denied your request. The Plan says that payment for the DME is made to the facility when the member is in a Part A skilled nursing facility (SNF) stay.
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 denied the durable medical equipment stating that the member was in a Part A covered Skilled Nursing Facility stay. The Plan has not forwarded any evidence that the member was in a Part A covered stay. 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 powered air mattress overlay (E0372), provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99203) and acupuncture services (97810, 97811) provided on August 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an OON office visit and acupuncture services. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized.
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 office visit (99203) and acupuncture services (97810, 97811) provided on August 4, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1833) provided on September 29, 2020.
You asked the Plan to pay for a knee orthosis. You say that this is supported in the records. The Plan denied your request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the Place of Service for durable medical equipment indicates the place in which the item is being used, i.e., patient's home is 12, skilled nursing facility (SNF) is 31, or end stage renal disease (ESRD) facility is 65. We looked at the file and Medicare rules. The item at issue was billed with an office place of service, which is not the place in which the item is used. Based on this information, we decided that Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis (L1833) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the hearing aids provided on
April 9, 2020.
You asked the Plan to pay an additional amount for the hearing aids. The Plan denied your request. The Plan says your insurance Plan paid $1,500 of the patient portion and anything over the $1,500 is the member's responsibility.
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. We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum benefit amount of $1,500 for the hearing aids and you are responsible to pay any additional amount. Therefore, we decided that the Plan does not have to pay an additional amount for the hearing aids provided on April 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient hospital admission. You say that the medical records provided support the need for an inpatient admission. The Plan denied your request. The Plan says the guidelines for coverage of an inpatient hospital stay have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 inpatient hospital admission Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for a total hip arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule are not satisfied. 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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88342, 88341) provided on October 21, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
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 88342 has a bundled relationship with code 88189 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Medicare rules also say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 88341 is an add-on code. As primary code 88342 is not payable in this case, the add-on code is also not payable. 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 (88342, 88341) provided on October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap vaccine you received on May 25, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. The records do not show that you have been injured or directly exposed to any illness related to the vaccine. Therefore, we decided that the Plan does not have to pay for the Tdap vaccine you received on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on March 26, 2020, by an OON
provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and paid. The
Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says
that there is no referring 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 an office visit provided on March 26, 2020, by an
OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 23, 2021 by a nonparticipating
provider.
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 were rendered by a non-participating 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.
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 office visit provided on April 23, 2021 by a
non-participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2021, by a non-participating provider.
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 were rendered by a non-participating 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.
The requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on May 12, 2021, by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of intraoral x-rays (D0210) provided on
April 14, 2021, and the periodontal maintenance (D4910) provided on May 12, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary, and you made
sure to use an in-network provider for this care. The Plan denied your request. The Plan says these services are
not covered by your dental benefit.
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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
complete series of intraoral x-rays (D0210) provided on April 14, 2021, and the periodontal maintenance
(D4910) provided on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code
70450-26) provided to the enrollee on March 19, 2021.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the CT scan have not been met. Our records indicate a National
Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 70450 and 70496. This
PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however,
an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 70450-26) provided to the enrollee on March 19, 2021.