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

We decided that the Plan does not have to reduce the copayment for the epidural steroid injection procedure you had at an outpatient hospital facility on July 2, 2021.
You asked the Plan to reduce the copayment for the epidural steroid injection procedure. You say that you had this procedure at an ambulatory surgical center, not a hospital, so your copayment should only be $300. 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 $350 copayment for outpatient surgery at an outpatient hospital facility.
You have been asked to pay a $350 copayment for the epidural steroid injection procedure. We have confirmed that the facility where you received these services is an outpatient hospital facility, not an ambulatory surgical center. The Plan's online directory shows this facility is considered a hospital. In addition, this facility is registered with the Centers for Medicare and Medicaid Services as a hospital, not as an ambulatory surgery center. That is why the epidural steroid injection procedure falls within the outpatient surgery at an outpatient hospital facility 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 reduce the copayment for the epidural steroid injection procedure you had at an outpatient hospital facility on July 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 22, 2021.
You asked the Plan to pay for hearing aids. The Plan denied your request. The Plan says an authorization is on
file for the out-of-network provider (142908444), however the authorization does not cover hearing aids.
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 you receive the services from any network hearing or hearing aid provider.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided from the
Plan's network hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of
hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids
provided on July 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99283 provided on
April 22, 2021.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99283 is emergency department visit for the evaluation
and management of a patient, which requires these 3 key components: An expanded problem focused history;
An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling
and/or coordination of care with other physicians, other qualified health care professionals, or agencies are
provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the
presenting problem(s) are of moderate severity.
We find that CPT code 99283 is not supported in the medical record. Specifically, this service was billed with a
primary/first-listed diagnosis of T38.0X5A identified as adverse effect of glucocorticoids and synthetic
analogues, initial encounter. Under Poisoning by, adverse effects of and Underdosing of drugs, medicaments
and biological substances" (T36-T50) there is a code first note which states to code first the adverse effect.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the
underlying etiology. For such conditions the ICD-10-CM has a coding convention that requires the underlying
condition be sequenced first followed by the manifestation. This means that this code was not billed with an
appropriate primary/first-listed diagnosis code. Based on this information, we decided that Medicare rules for
coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not
have to pay for the emergency department visit coded 99283 provided on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Synvisc.  You asked the Plan to pre-approve Synvisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.  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 Synvisc. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found you have a diagnosis of osteoarthrtis of the hip. The Food and Drug Administration has not stated that the requested drug is indicated for your condition. The Medicare approved drug compendia does not contain a supportive citation for the use of the requested drug in your clinical situation. Therefore, you do not meet criteria for the requested drug.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on September 18, 2019 by an out-of-
network (OON) provider.
You asked the Plan to pay for genetic testing. You say that this testing is covered and has been determined to
be medically necessary for management of the enrollee's condition. The Plan denied your request. The Plan
says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and
the ordering physician was also out-of-network with the 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 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 genetic testing provided on September 18, 2019 by
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.

You asked the Plan to pre-approve Durolane. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Durolane. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has pain related to osteoarthritis of the left knee, diagnosis confirmed with imaging studies. The enrollee has failed conservative treatment. The documentation does not support that the enrollee has tried and failed Hyalgan, Hymovis or Synvisc. There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet step therapy criteria. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81230, 81231, 81328, 81479) provided to the enrollee on June 17, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Review of the file shows that the enrollee had molecular genomics testing on June 17, 2020. The denial remains upheld as non-covered as Medicare denies coverage when a laboratory assays two (2) or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81230, 81231, 81328, 81479) provided to the enrollee on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on May 5, 2021.
You asked the Plan to pay for eyeglasses. You say that the nursing facility where the enrollee resides asked the provider to examine the patient. You say the patient does not have any input on who would be his optometrist. The Plan denied your request. The Plan says the eyeglasses are not covered by Medicare.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased from a Plan vision network provider. We looked at the file and the Plan's rules. The file shows that the eyeglasses were not purchased from a Plan vision network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on
May 5, 2021
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit provided from September 20, 2020, to September 22, 2020.    You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should have been waived because the enrollee was admitted to the hospital. The Plan denied your request. The Plan says you have been asked to pay 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $120 copayment for emergency services at an in-network emergency room.   The enrollee has been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The record shows the enrollee was in hospital observation. This means that 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 copayment for the emergency room visit provided from September 20, 2020, to September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies and materials coded as 99070 provided on January 28, 2021.  You asked the Plan to pay for the supplies and materials. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claim is missing required documentation.  The Plan must follow Medicare rules. Medicare rules say that there is required documentation that must be submitted that confirms that coverage criteria have been met.     We looked at the file and Medicare rules. In this case, this claim does not include an itemized billing statement or medical records that support the services as billed. Based on this information, we decided that Medicare rules for coverage of the supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the supplies and materials coded as 99070 provided on January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from May 24, 2021, to May 26, 2021.  You asked the Plan to pay for the acute inpatient hospital care. You say that you strongly believe the admission was appropriate and you expect full reimbursement because the services rendered could not have been provided in an outpatient setting. The Plan denied your request. The Plan says that this service was not medically necessary.  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 pay for the acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 24, 2021, to May 26, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for collection of capillary blood specimen (eg, finger, heel, ear stick) (CPT code 36416) provided to the enrollee on March 16, 2021.
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 36416 has a status indicator of 'B' on the Centers for Medicare & Medicaid Services (CMS) Physician Relative Value File and is always bundled into payment for other services not specified and no separate payment is made per Medicare.
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 collection of capillary blood specimen (eg, finger, heel, ear stick) (CPT code 36416) provided to the enrollee on March 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF care provided to the enrollee from November 3, 2019 through November 30, 2019.
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee no longer qualified for SNF coverage. The enrollee did not have documented skilled nursing needs.
The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pay for SNF care provided to the enrollee from November 3, 2019 through November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an advanced registered nurse practitioner at a plastic surgery office.

You asked the Plan to waive the copayment for the plastic surgery visit. You say that because you didn't see a doctor on this date, you should not have a copayment. 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 $40 copayment for specialist visits with a physician or practitioner. 

You have been asked to pay a $40 copayment for the plastic surgery visit. The specialist copayment applies to both physician and practitioner 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 copayment for the office visit you had with an advanced registered nurse practitioner at a plastic surgery office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus fee (D1999) provided on July 19, 2021.  You asked the Plan to pay for the dental service. You say that you had your broken molar repaired. You say that after 4 to 5 months your tooth still felt broken. You say that you went to the doctor for this emergency situation because you could not eat well. You say that you have $5,000 for dental work. You also say that you the service should be covered. The Plan denied your request. The Plan says the coronavirus fee is not a covered dental 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.  Though the Plan offers a dental benefit in excess of Medicare coverage, the coronavirus fee is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the coronavirus fee (D1999) provided on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a dispensing fee for hearing aids provided on May 13, 2021.  You asked the Plan to pay for a dispensing fee for hearing aids. The Plan denied your request. The Plan says the claim was received with a total billed amount of $4,660.00 and applied and paid the $500 hearing aid benefit appropriately.  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 appropriately paid for the hearing aids based on the Plan's hearing aid benefit. Therefore, we decided that the Plan does not have to pay for a dispensing fee for hearing aids provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis
with rheumatoid factor of multiple sites without organ or systems involvement. She has not tried and failed the
Plan's required drugs, Remicade or Inflectra and Simponi Aria. The records do not show that the required drugs
would be contraindicated or less effective; therefore, Actemra is not 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 pre-approve Actemra.