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

We decided that the Plan does not have to waive the copayment for an office visit on March 5, 2021. We also decided that the Plan does not have to waive the deductible applied to the electrocardiogram (EKG) provided on March 23, 2021, nor the inpatient physician services provided on April 1, 2021, to April 2, 2021, and on April 6, 2021.

You asked the Plan to waive the copayment for an office visit. You also asked the Plan to waive the deductible applied to an electrocardiogram (EKG) and to inpatient physician services. You say that these services should be covered because they are related to the Coronavirus (Covid-19). 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. Your contract with the Plan says that enrollees must pay a $35 copayment for services obtained from a specialist. Your contract with the Plan also says that there is a $500 deductible that is applied to certain services including outpatient diagnostics - not radiological diagnostic services (out-of-network only) and to inpatient hospital care, including physician services. 

You have been asked to pay a $35 copayment for the specialist office visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits. 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.

You have also been asked to pay $203.54 towards the $500 deductible for an electrocardiogram (EKG) and inpatient physician services.

Service:
Date of Service:
Allowed Amount:
Applied to Deductible:

Electrocardiogram (EKG)
March 23, 2021
$8.87
$8.87

Physician Services
April 1, 2021
$64.89
$64.89

Physician Services
April 2, 2021
$64.89
$64.89

Physician Services
April 6, 2021
$64.89
$64.89

Total:
$203.54

An electrocardiogram (EKG) falls within the other Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. Inpatient physician services fall under Inpatient Hospital Care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to these services. This cost sharing is a contractual obligation that had not been met at the time these services were processed.

Therefore, we decided that the Plan does not have to waive the copayment for an office visit on March 5, 2021. We also decided that the Plan does not have to waive the deductible applied to the electrocardiogram (EKG) provided on March 23, 2021, nor the inpatient physician services received on April 1, 2021, to April 2, 2021, and on April 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine.

You asked the Plan to pre-approve Buprenorphine. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Buprenorphine.

Benefits for Buprenorphine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0429) provided February 6, 2021.

You asked the Plan to pay for the ambulance services. You say that the services should be paid as billed. The Plan denied your request. The Plan says the documentation does not support the code billed.

The Plan must follow Medicare rules. Medicare rules say that in cases where the patient is pronounced deceased after the ambulance is called, providers must report the BLS code (A0428). 

We looked at the file and Medicare rules. The provider billed code A0429. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ambulance services (A0429) provided February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a TENS device and supplies, a pneumatic compression
vasopneumatic device, and multivitamin injections (compounded Nutria) provided on March 23, 2021.

You asked the Plan to pay for a TENS device and supplies, a pneumatic compression vasopneumatic device,
and multivitamin injections. You say that the requested items/services were a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the services
rendered were 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 pay for a TENS device and supplies, a pneumatic
compression vasopneumatic device, and multivitamin injections. Our reviewer says that the requested
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that, based on the medical records provided, there is no documentation that the enrollee had a
diagnosis/condition that met coverage criteria for the TENS device. There is no documentation that the enrollee
had a diagnosis/condition that met criteria for the pneumatic compression vasopneumatic device. Vitamin
injections into the nerve and musculoskeletal structures are not a Medicare covered service. The services
rendered did not meet Medicare criteria for medical necessity.

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 TENS device and supplies, a pneumatic compression vasopneumatic device,
and multivitamin injections have not been met. Therefore, we decided that the Plan does not have to pay for a
TENS device and supplies, a pneumatic compression vasopneumatic device, and multivitamin injections
(compounded Nutria) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the MRI of the lumbar spine. We decided that the Plan does not have to pay for the gadolinium-based contrast agent billed with code A9579.

You asked the Plan to pay for the MRI of the lumbar spine. You say that this claim should be paid. The Plan says that the incorrect code was used for the contrast agent. A decision regarding the MRI itself has been handled separately.

We decided that the Plan has to pay for the MRI of the lumbar spine.

The Plan follows Medicare rules. Medicare rules say that the Plan must make reasonable efforts to submit documentation to support their denials. 

In this case, the Plan did not review its original denial rationale. The claim shows that this service was denied with reason code 0527, meaning that "service was paid to another provider". The Plan made no reasonable attempts to provide documentation to support that payment was made to another provider for this service. The billing provider has produced records showing that this service was rendered. There is nothing in the file to suggest payment should not be made to this provider. As such, we find that the denial of payment for this code is not substantiated. Therefore, we decided that the Plan has to pay for the MRI of the lumbar spine.

We also decided that the Plan does not have to pay for the gadolinium-based contrast agent billed with code A9579.

The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT 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 gadolinium-based contrast agent billed with code A9579. Our reviewer says that the documentation does not support the use of code A9579 in this case. Our coding reviewer found the radiology report indicates that there was an injection of 6 milliliters of intravenous Gadavist. The correct code to report for this particular agent is A9585. Therefore, this service was coded incorrectly. 

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 gadolinium-based contrast agent billed with code A9579 have not been met. Therefore, we decided that the Plan does not have to pay for the gadolinium-based contrast agent billed with code A9579.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on August 12, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have 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 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 out of network physician services provided to the enrollee on August 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.

You asked the Plan to pre-approve genicular radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 genicular radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found given the failure of previous radiofrequency ablation therapy there is no indication for a repeat procedure. The review has determined that the items/services at issue in this case are not medically reasonable or necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for outpatient mental health services.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says an out-of-network exception cannot be 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for outpatient mental health services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system with expandable
controller for a power wheelchair (PWC).
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 covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is non-covered.
We looked at the file and Medicare rules. The requested power seat elevation system with controller is not
covered by Medicare because it does not serve a purpose that is primarily medical in nature. Therefore, we
decided that the Plan does not have to pre-approve a power seat elevation system with expandable controller
for a power wheelchair (PWC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the requested inpatient care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for inpatient care have not been met.
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 care are met in this case. Our physician reviewer found that detailed documentation is not evident in the case record regarding a significant past and/or current medical history that would place the enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient hospital care associated with knee arthroplasty is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg and accessories to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a prosthetic leg and accessories to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg and accessories to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment (oxygen equipment) obtained out of network on May 8, 2020.
You asked the Plan to pay for this equipment. You say that this equipment should be covered by the Plan. The Plan denied your request. The Plan says you obtained this equipment our of network without prior authorization.
Medicare rules say that plans can require enrollees to get care prior authorization. The Plan contract says that durable equipment requires prior authorization. The provider in this case is not a network provider with the Plan. The Plan did not pre-approve this equipment. 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 durable medical equipment (oxygen equipment) obtained out of network on May 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. 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 viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when specific criteria is 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 Orthovisc. Our reviewer says that the services are not medically necessary. Our physician reviewer found the progress note clearly states that you did not obtain relief from the prior viscosupplementation injection. Therefore, the request is deemed not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you would benefit from care at the SNF. The Plan denied your request. The Plan says that it is feasible to meet your needs at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a recliner chair.
You asked the Plan to pre-approve these services. You say that you have arthritis in your back and weakened legs. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) (K0554, K0553).
You asked the Plan to pre-approve a Dexcom G6 continuous glucose monitor . You say that this is medically necessary due to the enrollee's hypoglycemia. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM) (K0554, K0553).