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

 We decided that the Plan does not have to pre-approve use of Durolane.  

You asked the Plan to pre-approve Durolane. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Durolane.  

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 enrollee does not meet the Medicare criteria for a step therapy exception for Durolane. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc and Monovisc. The record does not show that these drugs would likely be less effective and/or 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Durolane.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on May 28, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician is a Hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization from the enrollee's insurance company. You also say that the rendering physician provided medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says this service was rendered by a non-contracted provider and there is no referral from a network provider. The Plan also says that there was no pre-authorization on file from the 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 subsequent nursing facility care (99309) provided on May 28, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injection services billed with code 64454 for date of service June 18, 2021.  You asked the Plan to pay for 3 units of code 64454. You say that the medical records substantiate the charges billed and support the frequency of the services rendered. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 64454 is 2. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 3 units of code 64454 have not been met. Therefore, we decided that the Plan does not have to pay for injection services billed with code 64454 for date of service June 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on April 26, 2021.  You asked the Plan to pay for the sedation services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment is made for this code according to Medicare rules.  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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  We looked at the file and Medicare rules. In this case, 99100 has a Status Code of "B" under the Physician Fee Schedule which stands for Bundled Code. As a result, payment for this service is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the amputation services coded 28805 provided on August 29, 2021.  You asked the Plan to pay for the amputation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 28805 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the amputation services have not been met. Therefore, we decided that the Plan does not have to pay for the amputation services coded 28805 provided on August 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76700), provided on August 16, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that there should not be a copayment. 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 $115 radiological diagnostic services copayment for outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay $103.43 out of the $115 radiological diagnostic services copayment for the ultrasound. This service falls within the outpatient diagnostic tests and therapeutic services and supplies 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 the ultrasound (76700), provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services provided on January 16, 2021.  You asked the Plan to pay for the services provided. You say that the medical records support the claim. The Plan denied your request. The Plan says the billed service cannot be verified.  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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided shows that only 15 minutes of critical care time were spent. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services provided on January 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you appear to be improving and should only require short-term additional acute care services that can be safely administered at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute (E0118).  You asked the Plan to pre-approve a crutch substitute. You say that this is medically necessary for your condition. The Plan denied your request. The Plan says the requested item 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 a crutch substitute. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested item is not proven safe or effective in the literature for your condition. Furthermore, the progress note submitted does not reveal sufficient objective evidence of support that this requested item will be safe to use in your home and that you have the proper functional ability to use the requested device.      We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute (E0118).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (88312, 88305, 87481, 87798) provided on June 22, 2021, by an out-of-network (OON) provider.  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 authorized.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (88312, 88305, 87481, 87798) provided on June 22, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided July 8, 2021.  You asked the Plan to pay for the diagnostic service. You say that after further review, you have made the necessary corrections below or included documentation that support the procedure performed. The Plan denied your request. The Plan says payment is not allowed for this service because it is not appropriate for the diagnosis 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 77080 is bone density scan of axial bones like hip, pelvis and spine.   We asked our coder 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 diagnostic service. Our reviewer says that the records provided do not meet the Medicare criteria. Our reviewer found 77080 26 was submitted to the health plan with a diagnosis code Z13.820 - Encounter for screening for osteoporosis, which is an inappropriate diagnosis code for this procedure. Therefore, there is no additional reimbursement allowed for 77080 26.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for bone density scan of axial bones like hip, pelvis and spine (77080) provided July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on March 25, 2021, through March 31, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that there should not be a copayment. 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 $285 copayment each day one through seven for inpatient hospital care.   You have been asked to pay a $285 copayment each day one through seven for the inpatient hospital care. This service falls within the inpatient hospital 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 the inpatient hospital care provided on March 25, 2021, through March 31, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 30, 2021.  You asked the Plan to pay for the ambulance service. You say that you should not be responsible for this bill. You say that you felt like you were going to die. You also say that you were advised there was no need for you to go to the hospital. The Plan denied your request. The Plan says there was no transport provided on the date of service. The Plan also says that since there was no transport provided there is no payable service.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   The ambulance company did not provide transport services on June 30, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. You say that you do not receive any enrollee information until after the services are rendered. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.  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 file shows that a urinary tract infection panel was provided. The requested provider in this case is not a network provider with the Plan. The referring provider is also not a network provider with the Plan. The Plan did not pre-approve the services at issue. There are insufficient medical records to show that the panel testing was indicated above the standard of care. 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 lab services provided on February 11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on April 6, 2021, to April 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the services provided. You say that the services were medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says the services were not urgent, emergent, or approved in advance.  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 wound care services provided on April 6, 2021, to April 22, 2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound (76770), provided on June 19, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that the cost share is wrong. 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 $160 radiological diagnostic services copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.   You have been asked to pay $94.15 out of the  $160 radiological diagnostic services copayment for the ultrasound. the ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 the ultrasound (76770), provided on June 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on April 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. You say that it is the facility's responsibility to get authorization. The Plan denied your request. The Plan says an authorization was not obtained prior to the services being rendered.   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 file shows that the enrollee was seen for a medication refill. 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 physician services provided on April 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ophthalmological services (92012) and extended examination (92083), provided on August 16, 2021.  You asked the Plan to waive the coinsurance for the ophthalmological services and extended examination. You say that this cost share is wrong. 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 vision services.   You have been asked to pay a 20% coinsurance for the ophthalmological services and extended examination. These services fall within the vision 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 coinsurance for the ophthalmological services (92012) and extended examination (92083), provided on August 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 29, 2021.  You asked the Plan to pay for the dental services. You say that you and the enrollee have the same plan. You say that you both went to the dentist on the same date. You say that your claim was processed. You say that the enrollee's claim was not paid. The Plan denied your request. The Plan says routine dental services are not covered. The Plan also says the dental rider was not effective on the date of service in this case.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the record shows that the dental rider was not effective for the enrollee on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on July 29, 2021.