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

We decided that the Plan does not have to waive the copayments for the telehealth visits you had with a nephrologist on January 21, 2021, and May 5, 2021.
You asked the Plan to waive the copayments for the nephrology telehealth visits. You say that you believe these copayments should be waived because they were telehealth visits. You say that because they are telehealth visits, you are not getting the same treatment as you would in the office. The Plan denied your request. The Plan says you were charged these copayments 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 $15 copayment for telehealth visits with a specialist.
You have been asked to pay a $15 copayment for each of the nephrology telehealth 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. Therefore, we decided that the Plan does not have to waive the copayments for the telehealth visits you had with a nephrologist on January 21, 2021, and May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical and imaging services rendered on April 30, 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 75710 is not supported and 36215 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, the CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. 

We find that CPT code 75710 is not supported in the medical record. Specifically, there is no documentation of a unilateral extremity angiography with radiological supervision and interpretation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

The medical records provided do not show that the procedure code 36215 billed with the -59 modifier is a distinct procedural service. Specifically, the records show that this service is included in approved code 36902. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met.

Therefore, we decided that the Plan does not have to pay for the surgical and imaging services rendered on April 30, 2021.
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 March 4, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 March 4, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided to the enrollee on April 22, 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 credentials of the provider do not qualify.
The Plan must follow Medicare rules. The rules say that psychological testing is limited to physicians, clinical psychologists, and on a limited basis, to qualified non-physician practitioners (e.g., speech language pathologists for aphasia evaluation). The rendering provider is not covered for this type of service. 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 outpatient mental health services provided to the enrollee on April 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dupixent.

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 self-administered drugs are not covered.

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 Dupixent.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation service (A0429) provided on May 27, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $325 copayment per trip for Medicare-covered ambulance services. You have been asked to pay a $325 copayment for the Medicare-covered ambulance service provided. 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 ambulance transportation service (A0429) provided on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick.
You asked the Plan to pre-approve these services. You say that the enrollee would like to continue on the medication. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Repatha Sureclick.
Benefits for these services 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 response and treatment, no transport (A0998) on December 25, 2020.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that the ambulance services should be classified as medically necessary. The Plan denied your request. The Plan says the ambulance benefit is a transportation benefit and without a transport 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 December 25, 2020. 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 ambulance response and treatment, no transport (A0998) on December 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on May 18, 2021.

You asked the Plan to pay for these services. You say that the Plan should cover this office visit. The Plan denied your request. The Plan says you did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for contact lenses (V2530) provided on
May 4, 2021.
You asked the Plan to pay an additional amount for contact lenses. You say that you should not be penalized
for ordering more prescriptions for contact lenses than your Plan allows. The Plan denied your request. The
Plan says you exceeded the $150 vision allowance benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says that you receive a $150 benefit allowance every 24 months that you can use to
pay for eyewear. If the eyewear you purchase costs more than $150, you pay the difference.
We looked at the file and the Plan's rules. The records show you exhausted your $150 maximum allowed vision
benefit. The records show you purchased contact lenses at a total price of $600. The Plan applied your $150
allowance which left you a balance of $450. Based on this information, we decided that the Plan's rules for
coverage of contact lenses have not been met. Therefore, we decided that the Plan does not have to pay an
additional amount for contact lenses (V2530) provided on May 4, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998)
provided on May 2, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you passed out on
the floor and the ambulance was called by your family. You say that you declined transport because you did
not want to go to the hospital in Holland. The Plan denied your request. The Plan says the Medicare ambulance
benefit is a transportation benefit and without a transport 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 May 2, 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 ambulance response and treatment, no transport
(A0998) provided on May 2, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on February 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that you never received services. The Plan denied your request. The Plan says the services are not covered.
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 provider is not eligible to participate in Medicare. 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 outpatient mental health services provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pantoprazole tablets.
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has used this medication for many years to manage his condition, and has tried and failed several alternative medications. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 pantoprazole tablets.
Benefits for self-administered drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that you are appealing this denial. The Plan denied your
request. The Plan says the denial of authorization for IRF service is correct.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical, and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation
supports a need for physical and/or occupational therapy, there is no documented need for an intensive
rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in
- and benefit from - the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient laser eye surgery you had on May 26, 2021.
You asked the Plan to waive the copayment for the outpatient laser eye surgery. You say that you were told this would be covered in full with no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this procedure ($260.80) is less than your copayment obligation, you are responsible for the full allowed 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 $275 copayment for outpatient surgery. You have been asked to pay a $275 copayment for the outpatient laser eye surgery. The outpatient laser eye surgery falls within the outpatient surgery 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 outpatient laser eye surgery you had on May 26, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient therapy services provided on November 2, 2020.

You asked the Plan to pay for the services provided. You say that the enrollee has tried other modalities that have not alleviated the pain. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in peer-reviewed literature.

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 the services provided. Our physician reviewer found that the enrollee has bilateral lower extremity neuropathic pain. She has tried Gabapentin and over the counter medications. She underwent electrical cell stimulation, vasopneumatic therapy and injection of a nutri-pharmaceutical blend. The services provided are not evidence-based therapy. Therefore, the procedures were 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 the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient therapy services provided on November 2, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for percutaneous left atrial appendage closure (LAAC) (Watchman procedure) provided on March 26, 2021.

You asked the Plan to pay for Watchman procedure. You say that you are appealing with supporting documentation. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the enrollee did not have a necessary diagnosis for this procedure.

The Plan follows Medicare rules. Medicare rules state that percutaneous left atrial appendage closure such as the Watchman procedure may be covered through Coverage with Evidence Development under certain conditions. 

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 Watchman procedure. Our reviewer says that this procedure meets the Medicare criteria for coverage. Our physician reviewer found the enrollee has atrial fibrillation and an absolute contraindication to anti-coagulation. This is an appropriate diagnosis for use of the Watchman left atrial occlude device (atrial fibrillation with an elevated CHA2DS2VASc score and an absolute contraindication to warfarin). All diagnostic and other implantation criteria under Medicare rules were met for the appropriate use of this 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 Watchman procedure have been met. Therefore, we decided that the Plan has to pay for percutaneous left atrial appendage closure (LAAC) (Watchman procedure) provided on March 26, 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 pay for the inpatient services provided August 6, 2019 to August 8, 2019.
You asked the Plan to pay for the inpatient 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 supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with A41.9 defined as Sepsis, Unspecified Organism. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found the enrollee presented to the emergency department with complaints of cough and fever for several months. On exam the enrollee was afebrile with a heart rate greater than 10) and clear lung fields. The enrollee's white blood count was less than 4000 and the enrollee's chest x-ray demonstrated a right lobe pneumonia. The enrollee was treated with intravenous fluids and intravenous antibiotics and admitted. The enrollee demonstrated no clinical or laboratory signs of sepsis. The review has determined that the documentation did not support the DRG 871 billed. The documentation did not support the principal diagnosis of A41.9 (Sepsis, Unspecified Organism). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided August 6, 2019 to August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services provided on March 1, 2021,
by an OON provider.

You asked the Plan to pay for the OON services. You say that you were told the doctor was covered under the
new plan. The Plan denied your request. The Plan says the claim for services denied appropriately.

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 OON services. Therefore, we decided that
the Plan does not have to pay for the pain management services provided on March 1, 2021, by an OON
provider.