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

We decided that the Plan does not have to pay for the physician services provided on July 12, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 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 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 physician services provided on July 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (T4523).
You asked the Plan to pre-approve incontinence supplies. You say that the adult diapers are medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (T4523).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic services (procedure code 95870) provided to the enrollee on June 1, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not 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, we have confirmed that code the services is a column II code to column I code 95861. 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 diagnostic services (procedure code 95870) provided to the enrollee on June 1, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography (77067) rendered by the out-of-network (OON) provider on June 10, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the screening mammography (77067) rendered by the out-of-network (OON) provider on June 10, 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 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 Synvisc. 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 right knee, diagnosis confirmed with imaging studies. The documentation does not support that the enrollee has tried and failed Orthovisc or Supartz FX. The documentation does not support that there is an indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 laboratory services provided to the enrollee on June 14, 2021.
You asked the Plan to pay for the services. You say that payment should be reconsidered. The Plan denied your request. The Plan says it cannot be determined how the enrollee came to the servicing provider, or whether the services are medically necessary.
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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Tempus xT assay is a custom oncology testing panel consisting of 648 genes with single nucleotide variants, indels and translocations measured by hybrid capture next-generation sequencing (NGS). The review
has determined that the services at issue in this case are 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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on September 7, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on
September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit received by the enrollee on June 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received by the enrollee are not a covered benefit when provided by an out of network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit received by the enrollee on June 16, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on March 18, 2021.  You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not submitted with the appropriate place of service code.  The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, this claim was billed with the laboratory place of service code but the record indicates the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.  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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there are limited large-scale, long-term references showing the safety and efficacy of the requested procedure in this clinical setting for the enrolle's condition. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for Intracept procedure at L5-S1 vertebral bodies is 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressures (CPAP) device.  You asked the Plan to pre-approve a backup battery. You say that this device is necessary. The Plan denied your request. The Plan says although this might be convenient, this is not covered according to Medicare rules.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway pressures (CPAP) device.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) services (70450) provided August 14, 2021.  You asked the Plan to pay for the CT services. You say that the documentation supports the services as billed. The Plan denied your request. The Plan says this claim was not billed as required by Medicare coding regulations.  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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) services (70450) provided August 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

 We decided that the Plan does not have to pay for naturopath services received from June 3, 2021, to September 2, 2021.  You asked the Plan to pay for the services. You say that your naturopaths are your primary doctors. The Plan denied your request. The Plan says there is a limit of six services per year.  The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan pays for the services of a naturopath only six times per year.   The records show that there six naturopathy visits billed and paid for between March 22, 2021, to June 11, 2021. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for naturopath services received from June 3, 2021, to September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device and appliance provided on June 9, 2021.  You asked the Plan to pay for codes E0675 and E0673 with modifier GZ. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. Medicare says that Plans shall automatically deny claim line(s) items submitted with a GZ modifier. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliance provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for an office visit provided on June 8, 2021.  You asked the Plan to waive the deductible for an office visit. You say that the documentation you received said nothing about a $198 deductible. You feel that for this reason you should not owe any deductible charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $198 deductible which applies to physician/practitioner services, including doctor's office visits.   You had an office visit on June 8, 2021. The record shows that you had paid $0 toward the $198 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $92.60.  The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $198 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on June 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit provided on June 8, 2021.   We note your complaint that the documentation you received did not mention deductible charges for 2021. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on July 23, 2021.  You asked the Plan to pay for code 0012M. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder are non-covered.  We looked at the file and Medicare rules. The service at issue is non-covered. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on July 23, 2021.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan does not have to pay for and waive the copayment for skilled nursing facility (SNF) care provided from April 23, 2020, to June 30, 2020.
You asked the Plan to pay for and waive the copayment for SNF care. You say that the enrollee's stay did not add up to 100 days, and the bill for $21,752.00 is the Plan's responsibility. The Plan denied your request. The Plan says the denial of payment for SNF care from June 7, 2020, to June 30, 2020 is correct, and the copayment amount that the enrollee is being charged is correct.
We decided that the Plan has to pay for the SNF care provided from June 8, 2020, to June 30, 2020.
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 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.
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 did not provide any medical records of this SNF stay for review. The Plan issued a Notice of Medicare Non-Coverage (NOMNC) to end the enrollee's SNF care on June 7, 2020. The Plan claims that the enrollee lost an appeal to continue coverage past this date. You say that this stay is the Plan's responsibility. Without medical records, we cannot determine whether the enrollee met the Medicare criteria for coverage of SNF care from June 8, 2020, to June 30, 2020. Therefore, the Plan has not shown that its decision to deny coverage for these dates is correct or medically justified according to Medicare rules. Therefore, we decided that the Plan has to pay for SNF care provided from June 8, 2020, to June 30, 2020.
We also decided that the Plan does not have to waive the copayment for the SNF care provided from April 23, 2020, to June 7, 2020.
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 $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for Skilled Nursing Facility (SNF) care. This portion of the SNF stay lasted 45 days, resulting in a copayment responsibility of $4,450. The enrollee has been asked to pay a $0 copayment per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for SNF care. SNF care falls within the Skilled Nursing Facility (SNF) care benefit category. 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 pay for and waive the copayment for skilled nursing facility (SNF) care provided from April 23, 2020, to June 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit injections.
You asked the Plan to pre-approve the Retracrit treatment. You say that the enrollee is a Jehovah's Witness and is unable to receive blood transfusions. The Plan denied your request. The Plan says the drug is not requested for a covered indication.
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 the Retracrit treatment. Our reviewer says that the requested treatment is not shown to be medically reasonable and necessary. Our physician reviewer found per the documentation, her provider requested Retacrit to treat her Iron deficiency anemia secondary to bleeding diverticulosis. The member has anemia secondary to bleeding diverticulosis, is of the Jehovah's Witness faith, and is refusing blood transfusion. The documentation does not support that the member is receiving the medication as Perioperative hemoglobin optimization before and after major elective surgery (eg, cardiac, spinal surgery). The review has determined that the requested use of Retacrit is not FDA-approved for the enrollee's diagnosis. Its requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 Retracrit treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit injections.