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

 We decided that the Plan does not have to pay for SNF services provided from July 13, 2021, through  July 31, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on July 6, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for SNF services provided from July 13, 2021, through July 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of impacted cerumen in one or both ears (69210) provided on August 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the removal of impacted cerumen in one or both ears. The Plan denied your request. The Plan says this provider is a non-participating provider with the Plan. The Plan also says that there is no referring provider involved in these services. The Plan also says that they did not authorize any services for this 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 removal of impacted cerumen in one or both ears (69210) provided on August 9, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for an ultrasound (76770) provided on August 29, 2021.  You asked the Plan to pay for an ultrasound. You say that this should be covered. The Plan denied your request. The Plan says this is not separately payable.  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 76770 is a column II code to column I code 93976. 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 an ultrasound (76770) provided on August 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (93880) provided August 25, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code billed and is not separately payable.  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 93880 is a column II code to column I code 76536. 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 radiology services (93880) provided August 25, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for Janus Kinase 2 (JAK2) genetic testing provided on April 10, 2021.  You asked the Plan to pay for JAK2 testing. You say that the enrollee's treating physician considered your expertise and specialized testing crucial to treating the enrollee's complex medical condition. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this test is not covered by Medicare for the diagnosis codes billed on this claim.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. Medicare rules say that JAK2 test code 81270 is covered for diagnosis code D75.1. The plan follows these rules.  This testing was ordered by an in-network provider. The file does not show that the plan provided notice that JAK2 testing would not be covered. This testing is covered by Medicare for the diagnosis for which it was ordered. Under Medicare rules, this means JAK2 testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for Janus Kinase 2 (JAK2) genetic testing provided on April 10, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on May 2, 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 the provider did not bill 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 imaging services provided to the enrollee on May 2, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services provided on August 28, 2021.  You asked the Plan to waive the copayment for ambulance services. You say that you were told that the services would be covered. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services.   You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall 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 services provided on August 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the myocardial perfusion imaging (78452) rendered by the out-of-network (OON) provider on May 4, 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 myocardial perfusion imaging (78452) rendered by the out-of-network (OON) provider on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 10, 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 the claim does not meet coding standards.  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 the denied codes are not supported in the medical record. Specifically, the records clearly show that these laboratory services were related to the treatment of end-stage renal disease (ESRD). Therefore, these services cannot be reported separately by the laboratory, and are the responsibility of the dialysis center. 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 May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 18, 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 the denied code remains not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on May 18, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for transthoracic echocardiography provided on August 9, 2021.  You asked the Plan to waive the copayment for transthoracic echocardiography. You say that you feel that there is a discrepancy in the charges and you should owe less than $30. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for non-radiological diagnostic services.  You have been asked to pay a $30 copayment for transthoracic echocardiography. Transthoracic echocardiography 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 transthoracic echocardiography provided on August 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on February 5, 2021.   You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contract providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.  The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on February 5, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Zilretta.  You asked the Plan to pre-approve Zilretta. You say that you would like reconsideration because the requested drug has previously provided immediate relief. The Plan denied your request. The Plan says that this is not approved for use more than once.  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 Zilretta. Our reviewer says that the record indicates that you have a diagnosis of  osteoarthritis of the knees.  The requested drug is being used for its current Food and Drug labelled indication. Our physician reviewer found the Food and Drug Administration has not restricted its use to a single time. The elements of the coverage criteria are satisfied.  The requested service is 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve Zilretta.   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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve five (5) additional visits with the day institute therapy program.  You asked the Plan to pre-approve five (5) additional visits with the day institute therapy program. The Plan denied your request. The Plan says the member no longer needs three therapy modalities to be administered concurrently in an intensive setting. The member may still qualify for outpatient physical and occupational therapies.  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 five (5) additional visits with the day institute therapy program. Our reviewer says that the day institute therapy services are not considered medically reasonable and necessary in this case. Our physician reviewer found that Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The neurology treatment plan states that the enrollee would benefit from additional physical therapy (PT) and occupational therapy (OT). Furthermore, the enrollee's high functional level in PT, OT, and speech therapy (ST) do not support he requires ongoing PT/OT/ST at an intensive day institute level. He is transferring with stand by assist (SBA), ambulating over 500 feet with SBA, eating a regular diet with thin liquids. He does not require the intensity of a day institute program for PT/OT and ST.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five (5) additional visits with the day institute therapy program have not been met. Therefore, we decided that the Plan does not have to pre-approve five (5) additional visits with the day institute therapy program.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 6, 2021.  You asked the Plan to waive the copayment for an ultrasound. You say that this was part of a post-operative follow-up visit and you should not be responsible for the 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $95 copayment for basic radiological services.   You have been asked to pay a $95 copayment for an ultrasound. An ultrasound falls within the outpatient hospital 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 an ultrasound provided on August 6, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve genicular nerve block, right knee.
You asked the Plan to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (64624). You say that the enrollee has severe right knee pain and cortisone injections are no longer giving him any relief. The Plan denied your request. The Plan says that destruction by neurolytic agent of genicular nerve branch is not considered standard of care for the enrollee's clinical condition.
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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Medical records were reviewed by the Plan but not provided. Therefore, we decided that the Plan has to pre-approve genicular nerve block, right knee.
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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve a home ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met.  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 home ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found Medicare does not cover a home ventilator when used as bilevel positive airway pressure (BiPAP). Certain BiPAP devices are capable of providing the average volume assured pressure support (AVAPS) mode of support, at less cost.  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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to waive the copayment for trigger point injections provided on June 4, 2021.  You asked the Plan to waive the copayment for trigger point injections. You say that you did not receive this service and these are false charges. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.  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 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 medical records. Without medical records we cannot determine whether or not services took place. Therefore, we decided that the Plan has to waive the copayment for trigger point injections provided on June 4, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided May 28, 2021, to June 4, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that the copayment is too much, and you cannot afford it. 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 $225 copayment per day, days 1-6 for inpatient hospital care.  You have been asked to pay a total of $1,350 ($225 copayment x 6 days = $1,350) for the inpatient hospital services. The inpatient hospital services fall 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 admission and services provided May 28, 2021, to June 4, 2021.