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

We decided that the Plan does not have to pay for the anesthesia services coded 00145 provided on May 20, 2021.

You asked the Plan to pay for the anesthesia 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 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 00145 is anesthesia for procedures on eye; vitreoretinal surgery. 

We find that CPT code 00145 is not supported in the medical record. Specifically, a claim that includes a surgery/procedure was not found that appropriately supports the anesthesia code. An operative note was not submitted verifying that a qualifying surgery was performed. The provider submitted only the anesthesia record for review which indicates that a cataract removal procedure was performed. The provider reported an anesthesia service that is inconsistent with the surgical procedure reported by the surgeon, which does not follow industry standard coding rules. The surgical procedure reported must align with the anesthesia services reported for reimbursement eligibility. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 00145 provided on May 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two Synvisc-one injections (J7325 x2).
You asked the Plan to pre-approve the Synvisc-one injections. You say that the enrollee has significant Osteoarthritis in both knees. The Plan denied your request. The Plan says Synvisc-one injections are not medically necessary for the enrollee's condition.
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 the Synvisc-one injections. Our reviewer says that the Synvisc-one injections are not medically reasonable and necessary for the enrollee. Our physician reviewer found evidence based medical peer-reviewed literature and guidelines support the use of viscosupplementation injections for the treatment of pain in enrollees with osteoarthritis of the knee when conservative treatment has failed. In this case, there is no documentation of the enrollee's response to conservative treatment, including the prior or most recent corticosteroid injections, to support proceeding with viscosupplementation at this time. Our reviewer found that there is no compelling rationale presented to support the medical necessity of this request at this time. Our physician reviewer also found that this request for Synvisc-one to the bilateral knee would not be considered medically reasonable and necessary and safe and effective for this enrollee's medical condition. 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 Synvisc-one injections have not been met. Therefore, we decided that the Plan does not have to pre-approve two Synvisc-one injections (J7325 x2).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, chest (71045) provided April 26, 2021.

You asked the Plan to pay for the radiologic service. You say that the contracted provider is not paid at contracted rate and the remittance advice failed to provide specific reasons for adjusting the claim. The Plan denied your request. The Plan says service paid to another provider.

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 71045 is radiologic examination, chest. 

We find that CPT code 71045 is not supported in the medical record. Specifically, non-participating providers are required to furnish necessary information to the health Plan when requested. The Plan had made multiple attempts to obtain needed records from the provider, without success. Based on this information, we decided that Medicare rules for coverage of the radiologic service have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, chest (71045) provided April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the pelvic and transvaginal ultrasounds (76830, 76856) provided on September 22, 2021.  You asked the Plan to waive the deductible for the ultrasounds. You say that the ultrasounds were medically necessary, and you feel the Plan should pay for these services. The Plan denied your request. The Plan says these services are covered, and the Plan has applied their discounted rate (allowed amount) to the services. However, you had not met your deductible prior to the date in question and are responsible for the full allowed amount for basic imaging services (e.g., general x-rays or ultrasounds) until the deductible is met.  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 there is $750 deductible which applies to basic imaging services (e.g., x-rays and ultrasounds).   The item or service you asked the Plan to waive the deductible for falls within the basic imaging services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible which applies to ultrasounds. This cost sharing is a contractual obligation that had not been met at the time the ultrasounds was received on September 22, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the pelvic and transvaginal ultrasounds (76830, 76856) provided on September 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Calquence.  You asked the Plan to pre-approve Calquence. 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 Calquence.   Benefits for Calquence 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 Entyvio.  You asked the Plan to pre-approve Entyvio. 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 Entyvio. Our reviewer says that the medication is not medically necessary. Our physician reviewer found in this case, the enrollee 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on August 9, 2021.

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 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 medical services provided to the enrollee on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on June 1, 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 S1015 and S8301 are not covered.

The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an echocardiography, transthoracic, real-time with image documentation (2D), with Doppler (93306) rendered on November 30, 2020.

You asked the Plan to waive the deductible for an echocardiography, transthoracic, real-time with image documentation (2D), with Doppler. You say that the doctor's office did not tell you that your copayment would not cover this test, and you did not know until you received the bill for $439. You also say that you did not know that the hospital owned the machine that was used for your testing. You also say you cannot afford to pay this bill. The Plan denied your request. The Plan says you were 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 there is $1,000 deductible which applies to certain items and services. The Plan deductible applies to an echocardiography, transthoracic, real-time with image documentation (2D), with Doppler. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible which applies to Outpatient Diagnostic Tests and Therapeutic Services and Supplies. You have been asked to pay $439 towards the $1,000 deductible for the Echocardiography, transthoracic, real-time with image documentation (2D), with doppler. This cost sharing is a contractual obligation that had not been met at the time an echocardiography, transthoracic, real-time with image documentation (2D), with Doppler was received on November 30, 2020. Therefore, we decided that the Plan does not have to waive the deductible for an echocardiography, transthoracic, real-time with image documentation (2D), with Doppler (93306) rendered on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the technical component of neurological testing services provided on March 9, 2021.  

You asked the Plan to pay for the technical component of neurological testing services. You say that you believe this claim has been submitted correctly and should be paid. The Plan denied your request. The Plan says only the facility where the enrollee was inpatient may be paid for these services as billed.  

The Plan must follow Medicare rules. Medicare rules say that items and non-physician services are included in payment to the facility during an inpatient hospital stay  

We looked at the file and Medicare rules. In this case, the technical component of these services are not separately paid to an entity other than the facility when the enrollee is inpatient. Based on this information, we decided that Medicare rules for coverage of the technical component of neurological testing services have not been met. Therefore, we decided that the Plan does not have to pay for the technical component of neurological testing services provided on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021.  

You asked the Plan to pay for the laboratory 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 separately payable.  

The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve back surgery.  You asked the Plan to pre-approve back surgery. 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 back surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria is not met. You are a smoker. There is no documentation of smoking cessation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of back surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve back surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care, provided on August 3, 2021, through September 1, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $184 copay per a day 21-100 for skilled nursing facility (SNF) care. You have been asked to pay a $184 copay per a day 21-100 for the SNF care. This service falls within the skilled nursing facility (SNF) care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) care, provided on August 3, 2021, through September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. 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 must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 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 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 IRF admission is not medically necessary based on lack of medical complexity and nursing needs and high functional level.

Documentation does not support the necessity for admission to 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on August 12, 2021.

You asked the Plan to pay for an eye refraction. You say that you disagree with the denial. The Plan denied your request. The Plan says eye refractions are only covered by your Plan if performed by a participating provider and performed as a routine screening. The Plan also says the service is not a covered benefit since it was a medical vision check.

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 an eye refraction is only covered by the Plan when it is performed as part of a routine screening by a participating provider. 

We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on August 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87481, 87491, 87511, 87529, 87591, 87640, 87651, 87653, 87661, 87798, 87801) provided on August 10, 2021.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with diagnosis codes that support necessity.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87481, 87491, 87511, 87529, 87591, 87640, 87651, 87653, 87661, 87798, 87801) provided on August 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic anoscopy (46601) provided on July 14, 2021.

You asked the Plan to pay for a diagnostic anoscopy. You say that the procedure at issue is part of a routine that you need for your health. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate Current Procedural Terminology (CPT) code. In this case, we have confirmed that code 46601 is a column II code to column I code 45190. 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 a diagnostic anoscopy (46601) provided on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the microslide consultation rendered on March 12, 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 covered.  

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   

In this case, the MUE for CPT code 88321 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 microslide consultation rendered on March 12, 2021.