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

 We decided that the Plan does not have to pay for a specialist office visit (99214) and a diagnostic nasal endoscopy (31231) provided on May 19, 2021, to August 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for a specialist office visit and a diagnostic nasal endoscopy. You say that you were informed that the denial is made on the basis that this provider does not accept Medicare payments and in your opinion, the decisions this provider made to accept or not accept Medicare payments and the management of his finances should not affect me, nor as a patient. The Plan denied your request. The Plan says this provider appears is an opt out provider, and so the beneficiary will be responsible for the full cost of services rendered by a provider not eligible to participate in Medicare.  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 a specialist office visit (99214) and a diagnostic nasal endoscopy (31231) provided on May 19, 2021, to August 25, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 19, 2021, through January 20, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the hospital care was medically necessary. The Plan denied your request. The Plan says no evidence was provided that member's treatment needs cannot be met at a less restrictive, outpatient level of care such as observation beyond emergency room care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the hospital for a scheduled parotidectomy, which was without complication. The enrollee tolerated diet and the physical exam was unremarkable during the initial short-term post-operative care. The enrollee's vitals were stable. There was insufficient evidence from the documentation that the enrollee required hospital services that would likely cross 2 midnights.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 19, 2021, through  January 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiologic examination, of the spine, cervical; 4 or 5 views (72050) rendered by the out-of-network (OON) provider on April 9, 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 radiologic examination, of the spine, cervical; 4 or 5 views (72050) rendered by the out-of-network (OON) provider on April 9, 2021.
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 from September 17, 2021, to September 22, 2021.  You asked the Plan to waive the copayment for inpatient hospital care. You say that you do not understand why you owe this amount. The Plan denied your request. The Plan says you were admitted as inpatient from September 17, 2021, to September 22, 2021. You are responsible for a $250 copayment for each of the first five days of an inpatient hospital stay. This claim was processed in accordance with your contract.  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 each of the first five days of an inpatient hospital stay.   You have been asked to pay a $1,250 copayment for a five-day inpatient hospital stay ($250 x 5 days = $1,250). 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 from September 17, 2021, to September 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).  You asked the Plan to pre-approve Gel-One. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.  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 Gel-One. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not trialed one preferred viscosupplemental treatment such as Durolane, Monovisc, or Synvisc-One. Step therapy, as outlined by the Plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Gel-One (J7326).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xarelto.  You asked the Plan to pre-approve the Xarelto. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan 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 Xarelto.    Benefits for the Xarelto 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: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox.  You asked the Plan to pre-approve Botox. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.    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 Botox. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Xeomin before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endoscopy rendered on August 9, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 43260 is 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.  In this case, the CPT Code Manual definition of code 4326 is endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).  We find that CPT code 4326 is not supported in the medical record. Specifically, the records show that a sigmoidoscopy was performed and there is a more appropriate code for these services. 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 pay for the endoscopy rendered on August 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2).  You asked the Plan to pre-approve the endosteal implants. You say that you were approved last year for the implants, but the authorization expired. You also say that the implants are medically necessary. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two surgical placements of implant bodies: endosteal implants (D6010 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) provided on October 19, 2021.  You asked the Plan to pay for the custom fabricated abutment. You say that you should not have to pay $2,300 when the Plan only has to pay $700. You also say that the dental school assumed the Plan was going to pay the $1,021 that is why they did not make you pay when you were there. The Plan denied your request. The Plan says your contract does not cover this service.  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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on August 19, 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 (99204) rendered by the out-of-network (OON) provider on August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 12, 2020, to November 30, 2020.

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 code. 

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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the Daily Skilled Note dated 11/14/20 documents that indoor mobility (ambulation) is "Unknown". The documentation does not support that the enrollee's usual walking performance is with partial/moderate assistance. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from November 12, 2020, to November 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on September 25, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head).  Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on September 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 13, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 laboratory services provided on September 13, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve acute inpatient hospital care.  You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient medical care is medically necessary in this case. The Plan denied your request. The Plan says that the documentation does not support the medical necessity of acute inpatient hospital care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the review indicates that the enrollee is a 66-year-old male with a history of degenerative joint disease, emphysema/chronic obstructive pulmonary disease, hyperthyroidism, hypertension, and smoker who was transferred from outside hospital on February 15, 2021, with worsening intractable back and rib pain. Member reports his "hip gave out" due to sudden rib pain 3 weeks ago. Fell again a week later upon rising from a sitting position and feeling lightheaded. Back and rib pain have gotten progressively worse and was not improving with home Norco he takes for chronic degenerative joint disease in his lower back for 8 years. Reports and increased cough with occasional brown sputum produced and occasional shortness of breath when the pain is exacerbated. Reports one episode of bright red blood in his stool. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital care.   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 dry needling.  

You asked the Plan to pre-approve dry needling. You say that dry needling is medically necessary. The Plan denied your request. The Plan says dry needling is considered experimental and investigational.  

The Plan follows Medicare rules. Medicare rules say that All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare.  

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 dry needling. Our reviewer says that dry needling is not medically necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has polyosteoarthritis. The provided documentation does not indicate that the requested service is being prescribed for back pain. The elements of the coverage criteria are not satisfied. The requested service is not 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 dry needling have not been met. Therefore, we decided that the Plan does not have to pre-approve dry needling.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for domiciliary or rest home visit (99334) provided on October 22, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that the referring provider requested this provider be called in to see the patient as an attending provider in an outpatient capacity. You also say that there is a medical necessity pre-established with the patient and the facility for this provider to provide services to the patients needing care. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 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 domiciliary or rest home visit (99334) provided on October 22, 2021, by an out-of-network (OON) provider.