Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided July 14, 2021.
You asked the Plan to pay for the office visit. You say that the office visit was medically necessary. The Plan
denied your request. The Plan says the claim cannot be paid 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.
We find that CPT code 99214 is not supported in the medical record. Specifically, the claim was billed with an
invalid place of service (23, emergency room). Based on this information, we decided that Medicare rules for
coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an
office visit (99214) provided July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the oncology visit to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the oncology visit. You say that you would like reconsideration because your cancer is spreading and you need to be seen by a specialist as soon as possible. The Plan denied your request. The Plan says there are in-network providers available to render your necessary care.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the oncology visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement power scooter.

You asked the Plan to pre-approve these services. You say that your current scooter doesn't fit in your primary care physician's office, elevator, or transportation van. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a replacement power scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you disagree with the denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab services (36415, 85610, 85025) provided August 12, 2021 to August 27, 2021.
You asked the Plan to waive the copayment for the lab services. You say that this copayment should be waived. The Plan denied your request. The Plan says the correct copayment was applied.
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 freestanding lab services. You have been asked to pay a $20 copayment for the lab services. The lab services fall within the freestanding lab 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 lab services (36415, 85610, 85025) provided August 12, 2021 to August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection.
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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness is covered to control multiple power options. We looked at the file and Medicare rules. The file shows that the requested expandable controller with harness and electronic connection is not needed to control the approved power switches. Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness and electronic connection.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the endoscopy procedures (45385, 45381, and 45380) provided on August 25, 2021.
You asked the Plan to pay for the endoscopy procedures. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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 rules also say if Field 21 of the Medicare Fee Schedule Database (MFSDB) contains an indicator of "3," and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that the MFSDB indicator, base endoscopy, and special rules for endoscopies mean that codes 45385, 45381, and 45380 are bundled into 45390. However, the referenced rules do not indicate that these codes are bundled. The referenced rules indicate that the Plan must pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. The submitted documentation does not indicate that the Plan has done so. Therefore, we decided that the Plan has to pay for the endoscopy procedures (45385, 45381, and 45380) provided on August 25, 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 lab services (G0483) provided June 18, 2021.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the documentation provided does not support the services 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. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided June 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 additional Home Health (HH) Physical Therapy (PT) visits and 82 additional Home Health Aide (HHA) visits.

You asked the Plan to pre-approve 15 additional HH PT visits and 82 additional HHA visits. You say that the additional visits are medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of the additional visits.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 15 additional HH PT visits and 82 additional HHA visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the documentation doesn't support that you require additional skilled rehab services to provide treatment that is medically necessary. You do not require additional skilled rehab services to effectively provide treatment, care, and/or services to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 15 additional HH PT visits and 82 additional HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 additional Home Health (HH) Physical Therapy (PT) visits and 82 additional Home Health Aide (HHA) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services received on July 31, 2021.
You asked the Plan to pay for the services. You say that the copayment should be $15. 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 $45
copayment for specialist office visits.
You have been asked to pay a $45 copayment for the services. The services fall within the specialist office
visits benefit category, as the services constituted more than a routine eye exam. 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 vision services received on July 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seat elevator cable set (K0108).

You asked the Plan to pre-approve seat elevator cable set. You say that please review the attached medical
documentation to support the need of the custom medical equipment being requested. The Plan denied your
request. The Plan says this item does not serve a primary medical purpose and is statutorily non-covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We looked at the file, and Medicare rules. The seat elevator cable set is requested for an item (seat elevator)
that is not medically necessary and is no longer being requested. The seat elevator had been withdrawn from
the appeal. Therefore, this item is no longer needed. Based on this information, we decided that Medicare rules
for coverage of seat elevator cable set have not been met. Therefore, we decided that the Plan does not have to
pre-approve seat elevator cable set (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an urgent care visit provided on September
16, 2021.
You asked the Plan to waive the copayment for the urgent care visit. 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 $50
copayment for Urgently needed services.
You have been asked to pay a $50 copayment for an urgent care 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 an urgent care visit provided on September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the enrollee would benefit from intensive therapy services, or three hours of therapy per day in an inpatient setting. The Plan denied your request. The Plan says the enrollee did not meet the criteria for coverage of IRF care. The Plan says that the care needed can be provided safely in a less intensive setting.  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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (81340, 81342) rendered by the out-of-network (OON) provider on July 22, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81340, 81342) rendered by the out-of-network (OON) provider on July 22, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies, life sustaining situation and routine disposable supplies provided on June 29, 2021.

You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says oxygen and oxygen supplies, life sustaining situation and routine disposable supplies are not separately payable.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance oxygen and oxygen supplies, life sustaining situation and routine disposable supplies provided on June 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a regimen of carboplatin, pembrolizumab, pemetrexed.  You asked the Plan to pre-approve the regimen of carboplatin, pembrolizumab, pemetrexed. You say that you would like reconsideration because the requested drug regimen is medically necessary. The Plan denied your request. The Plan says the requested regimen is not supported by National Comprehensive Cancer Network (NCCN) guidelines, specifically the continuation of Keytruda because the member has progressed on Keytruda.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 regimen of carboplatin, pembrolizumab, pemetrexed. Our reviewer says that carboplatin, pembrolizumab, pemetrexed is not a standard of care for progression of disease on single agent pembrolizumab. The member has progression in at least 2 sites and standard therapy would be to change to chemotherapy. Our physician reviewer found there is not data to support adding chemotherapy to pembrolizumab when there appears to be resistance to pembrolizumab. The combination 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 the regimen of carboplatin, pembrolizumab, pemetrexed have not been met. Therefore, we decided that the Plan does not have to pre-approve a regimen of carboplatin, pembrolizumab, pemetrexed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for a podiatrist visit provided on July 26, 2021.
You asked the Plan to waive the deductible for the podiatrist visit. You say that did not know the provider was
out of network. The Plan denied your request. The Plan says the correct amount was applied to your out-ofnetwork
(OON) deductible
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that there is $1,500 deductible which applies to certain items and services.
The item or service you asked the Plan to waive the deductible for falls within Podiatry Services the benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,500
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not
been met at the time the podiatrist visit was received on July 26, 2021. Therefore, we decided that the Plan does
not have to waive the deductible for a podiatrist visit provided on July 26, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve medical services from an out of network (OON) interventional radiologist.  You asked the Plan to pre-approve the OON interventional radiologist services. You say that the enrollee needs to receive treatment closer to her home and at the location she is familiar with. The Plan denied your request. The Plan says that they have network providers who can treat the enrollee.  Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers.   The requested provider is a non-contract provider. The requested provider is an interventional radiologist and the Plan's referral was to a provider who was 76 miles from the enrollee's home address. We were able to confirm that the contract provider the Plan has referred the enrollee to is not located within reasonable distance and travel time from the enrollee's home. Under Medicare rules, this means that the contract provider is not accessible to the enrollee. Therefore, we decided that the Plan has to pre-approve medical services from an out of network (OON) interventional radiologist.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic femoral nerve block provided on June 7, 2021,
billed with code 64447.
You asked the Plan to pay for the services as billed. You say that this should not be considered part of the
anesthesia because the block was done prior to commencing anesthesia. The Plan denied your request. The
Plan says this was billed with a Column 1 code for which there is no allowable modifier.
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 64447
is a column II code to column I code 64624.
This pair has a modifier indicator of 0, meaning that a modifier cannot be used 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 anesthetic femoral nerve block provided on June 7, 2021, billed with code 64447.