Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provided on July 6, 2021.
You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says your Plan does not have out-of-network benefits.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when purchased with a network optical provider. We looked at the file and the Plan's rules.
The file shows that the eyeglasses were not provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on July 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Actemra.  You asked the Plan to pre-approve Actemra. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Actemra. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that supports that the Actemra meets Medicare criteria for being safe and effective or medically reasonable and necessary 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 Actemra have not been met. Therefore, we decided that the Plan does not have to pre-approve Actemra.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 10, 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 99152 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 99152 is moderate sedation services by other qualified
health care professional requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of
first 15 minutes of an independent trained observer to monitor the enrollee's level of consciousness and
physiological status. 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 moderate sedation services
rendered on May 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Xolair.  You asked the Plan to pre-approve Xolair. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Xolair. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Xolair is medically reasonable and necessary for the enrollee. The documentation does not support that the Xolair is safe and effective 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 Xolair have not been met. Therefore, we decided that the Plan does not have to pre-approve Xolair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser cataract surgery to be provided by the requested
out-of-network provider.
You asked the Plan to pre-approve laser cataract surgery to be provided by the requested out-of-network
provider. You say that the in-network provider cannot do laser assisted cataract surgery, which is what you
need. The Plan denied your request. The Plan says members may obtain services from out-of-network
providers if the services are emergent/urgent or not available within the network. The services are not emergent
or urgent and are available at a network provider's office.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve laser
cataract surgery to be provided by the requested out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health skilled nursing (SN) and home health aide
(HHA) visits.
You asked the Plan to pre-approve the requested home health services. You say that it is felt that this care is
necessary. The Plan denied your request. The Plan says there is no medical need for the requested services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the requested home health services. Our
reviewer says that the requested home health services are not shown to be medically necessary. Our physician
reviewer found the enrollee is a male with a history of gunshot wound with C1-C4 incomplete quadriplegia. He
requires ostomy care but refused wound center referrals. Limited medical documentation was submitted. Based
on this, the enrollee does not have documented skilled needs from a nurse or a therapist. As such, neither the
SN or HHA service are shown to be medically necessary or reasonable.
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 requested home health services have not been met. Therefore, we decided
that the Plan does not have to pre-approve home health skilled nursing (SN) and home health aide (HHA)
visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on July 19, 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 July 19, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.   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 Keytruda. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the provided documentation, there was insufficient support made for continuing Keytruda, therefore, it will be considered not medically necessary for this enrollee. The cancer had progressed while he was on Keytruda, suggesting that it was not effective for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Remicade.  You asked the Plan to pre-approve Remicade. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 Remicade. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Avsola, Inflectra, and Renflexis would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have to pre-approve Remicade.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Tangential biopsy of skin (11103) provided on  May 6, 2021.  You asked the Plan to pay for code 11103. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11103 is a column II code to column I code 17110. 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 the Tangential biopsy of skin (11103) provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 24, 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 codes 84436 and 84479 are not separately payable.
The rules say that, for edits with a modifier indicator of 0, the Column 2 code cannot be paid regardless of
whether a modifier is used.
The provider submitted a claim for procedure codes 84436 (assay of total thyroxine), 84479 (assay of thyroid,
T3 or T4), and 84439 (assay of free thyroxine). Codes 84436 and 84479 are column II codes with a modifier
indicator of 0 when billed with column I code 84439. The column II codes are therefore not separately payable.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 24,
2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (CPT code 72100) and the office visit (CPT code 99204) provided on July 14, 2021, by a chiropractor.
You asked the Plan to pay for the services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the services or items in question are not covered under your contract under any normal circumstances.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chest x-ray (CPT code 72100) and the office visit (CPT code 99204) provided on July 14, 2021, by a chiropractor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the spinal injections provided from
September 30, 2020, through November 11, 2020.
You asked the Plan to waive the copayment for the spinal injections. 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 (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200
copayment for surgery at an ambulatory surgical center.
The injections you received are considered surgical services. You have been asked to pay a $200 copayment
for the spinal injections. The spinal injections fall within the Outpatient Surgery, Including Services Provided
at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 spinal injections provided from September 30, 2020,
through November 11, 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 July 24, 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 July 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient care provided to the enrollee from April 13, 2021, to April 26, 2021 under diagnosis related group (DRG) 871.  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 Medicare billing criteria are not met. 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.  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 these services. Our reviewer says the documentation does not support a primary diagnosis of unspecified sepsis.  Although, sepsis is listed, during the course of the hospital stay, patient was "afebrile, with negative blood cultures and without leukocytosis".  Sepsis requires the presence of infection, which is not documented during this hospital stay. Medicare billing criteria are not met. 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 inpatient care provided to the enrollee from April 13, 2021, to April 26, 2021 under diagnosis related group (DRG) 871.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolotherapy, the electrical stimulation services, and related services provided on June 24, 2021.  You asked the Plan to pay for the prolotherapy, the electrical stimulation services, and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that transcutaneous electrical nerve stimulation (TENS) device is only covered for treatment of muscle atrophy and use for walking in patients with spinal cord injuries. The rules say that pneumatic/vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema.  We looked at the file and Medicare rules. The prolotherapy services were billed under a trigger point injection code, which is a misrepresentation of the actual services rendered. This means this service was coded incorrectly. Transcutaneous electrical nerve stimulation (TENS) device is only covered for treatment of muscle atrophy and use for walking in patients with spinal cord injuries. Review of the file does not support that the enrollee had one of these indications for this service to be covered. Pneumatic/vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. Review of the file does not support that the enrollee had one of these indications for this service to be covered. Based on this information, we decided that Medicare rules for coverage of the prolotherapy, the electrical stimulation services, and related services have not been met. Therefore, we decided that the Plan does not have to pay for the prolotherapy, the electrical stimulation services, and related services provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 28, 2020.  You asked the Plan to pay for the drug testing. 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 by the documentation.  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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.  We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on April 3, 2021.  You asked the Plan to waive the copayment for the laryngoscopy. You say that you should only have a $45 specialist copayment. You say you should not be charged an additional $50 for the testing. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for outpatient diagnostic tests. Your contract also clearly says that diagnostic tests at a physician's office are subject to additional cost sharing.   You have been asked to pay a $50 copayment for the laryngoscopy. The laryngoscopy falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the laryngoscopy provided on April 3, 2021.