Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 10, 2022.  You asked the Plan to pre-approve the SNF care. The Plan denied your request. The Plan says that a continued SNF stay is not medically necessary.  The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.  We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before February 10, 2022. It is noted on the provided NOMNC that your spouse is the responsible party, that you referred to the spouse, and you were confused. The provided NOMNC does not show that your spouse was notified of the NOMNC, and it is not signed or dated. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after February 10, 2022.   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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 19, 2021.  You asked the Plan to waive the copayment for ambulance transport. You say that you were admitted to the hospital so this should be waived. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.  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 $125 copayment for each one-way ambulance trip.   You have been asked to pay $125 copayment for ambulance transport. Ambulance transport falls within the Ambulance Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 19, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on February 2, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you are now receiving bills from a collection agency. The Plan denied your request. The Plan says you have been charged 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). Your contract with the Plan clearly says that you must pay a $90 copayment for each emergency room visit.   You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency Care 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 an emergency room (ER) visit provided on February 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram services (93010) provided on July 28, 2021.  You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier to bypass the edit.  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 93010 is a column II code to column I code 92960. 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 electrocardiogram services (93010) provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oxygen concentrator provided on July 25, 2021, through August 25, 2021.  You asked the Plan to pay for the oxygen concentrator. You say that you would like reconsideration because you do not want to use this equipment any longer and should not be billed for it. The Plan denied your request. The Plan says there is no documentation of recent pO2 or arterial oxygen saturation to qualify for the oxygen concentrator.  The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen.    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 oxygen concentrator. Our reviewer says that home supplemental oxygen is not medically necessary. Our physician reviewer found the clinical note shows no hypoxemia at rest or during walking.  Supplemental oxygen was no longer necessary at that point.     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 oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on July 25, 2021, through August 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the therapeutic radiology services provided on July 1, 2021.  You asked the Plan to waive the coinsurance for the therapeutic radiology services. You say that the services should be covered. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare Part B prescription drugs.   You have been asked to pay a 20% coinsurance for the therapeutic radiology services. the therapeutic radiology services falls within the Medicare Part B prescription drugs 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 coinsurance for the therapeutic radiology services provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia (01402) provided on September 2, 2021.  You asked the Plan to pay for anesthesia. You say that this was coded correctly. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that a Medicare Physician Fee Schedule Database (MPFSDB) Status Indicator of J indicates anesthesia services. No relative value units or payment amounts are made for anesthesia codes on the database. They are only used to facilitate the identification of anesthesia services.    We looked at the file and Medicare rules. Code 01402 has a status indicator of J. This code is only used to identify services and is not payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia (01402) provided on September 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee.  You asked the Plan to pre-approve these services. You say that this procedure is medically necessary in order to achieve a quality of life. The Plan denied your request. The Plan says that the applicable guidelines do not support the use of this device for long-term relief of back and leg pain.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device placement surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve osseous surgery (D4260), and bone replacement graft (D4263).  You asked the Plan to pre-approve the dental services. You say that you need this surgery. You say that you will lose you tooth otherwise. The Plan denied your request. The Plan says osseous surgery is not listed as covered. The Plan says that bone replacement graft is not listed as a covered service either.  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 osseous surgery and bone replacement graft are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve osseous surgery (D4260), and bone replacement graft (D4263).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lucentis (J2778).  You asked the Plan to pre-approve Lucentis. You say that Lucentis is clinically indicated for cystoid macular edema. The Plan denied your request. The Plan says this drug does not meet coverage criteria.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and Drug Administration (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 Lucentis. Our reviewer says that Lucentis (J2778) is not medically reasonable and necessary for the enrollee. Our physician reviewer found that the FDA has not stated that the requested drug is indicated for the enrollee's condition. Our reviewer found that the Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service cannot be recommended.       We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis (J2778).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis tablets.  You asked the Plan to pre-approve the Eliquis tablets. You say that the patient has been stable on the current medication since March of 2014. The Plan denied your request. The Plan says Eliquis is a self-administered drug and does not fall under Part B coverage.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.   Benefits for the Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Opzelura.  You asked the Plan to pre-approve Opzelura. You say that the enrollee has tried and failed tacrolimus and ketoconazole cream. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Opzelura.   Benefits for Opzelura may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve blocks.  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 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found that you have chronic left knee pain due to osteoarthritis. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain. The services are therefore 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 genicular nerve blocks.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on May 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so payment should be made. The Plan denied your request. The Plan says there was no prior authorization obtained for the enrollee to see 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 an office visit provided on May 17, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on July 15, 2021.  You asked the Plan to waive the copayment for an ultrasound. The Plan denied your request. The Plan says the claim processed with the correct copayment.  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 Basic Radiological Services, Specialist's Office.   You have been asked to pay a $40 copayment for an ultrasound. The ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies, Basic Radiological Services, Specialist's Office 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 an ultrasound provided on July 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the preventive procedure (D1999) and two additional periapical x-rays, or pay more for the comprehensive exam, cleaning, fluoride, and two periapical x-rays provided on September 28, 2020 by an out-of-network (OON) provider.    You asked the Plan to pay for the preventive procedure and additional periapical x-rays, and to pay more for the comprehensive exam, cleaning, fluoride, and two periapical x-rays. You say that the provider tried submitting the claim four times, and the claim being submitted late was out of your control. The Plan denied your request. The Plan says the preventive procedure is not a covered benefit, and you have exhausted your benefit for the additional periapical x-rays. The Plan also says that these services were rendered by an OON provider, and you are responsible for your copayment plus the difference between the dentist's submitted fee and the Plan's allowed amount for these services.  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, unspecified preventive procedure (D1999) not among those covered under this benefit. The contract says that you are limited to four periapical x-rays in a 12-month period. The record shows that you received two periapical x-rays on December 2, 2019, and four periapical x-rays on September 28, 2020, two of which were covered by the Plan, and your periapical x-rays benefit has been exhausted. The contract also says that you are responsible for the difference between the provider's billed amount and the Plan's allowed amount for covered dental services that are received OON. Therefore, we decided that the Plan does not have to pay for the preventive procedure (D1999) and two additional periapical x-rays, or pay more for the comprehensive exam, cleaning, fluoride, and two periapical x-rays provided on September 28, 2020 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (81162, 81191, 81206, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81404) provided on April 26, 2021.  You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81162, 81191, 81206, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81404) provided on April 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an angiography (75710) provided on September 3, 2021.  You asked the Plan to pay for an angiography. You say that this is supported in the records. The Plan denied your request. The Plan says this is not separately payable.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Specifically, the records show that this was performed in conjunction with the primary procedure, 37227. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.      Therefore, we decided that the Plan does not have to pay for an angiography (75710) provided on September 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the built-in whirlpool (E1310) and tax (D9999), provided on August 19, 2021.  You asked the Plan to pay for the built-in whirlpool and tax. You say that the item is medically necessary. The Plan denied your request. The Plan says you obtained this item through a provider that is not enrolled in Medicare.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the built-in whirlpool (E1310) and tax (D9999), provided on August 19, 2021.