Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound (76705) provided on July
23, 2021.
You asked the Plan to waive the copayment for the ultrasound. 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 $110
diagnostic radiology copay for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.
You have been asked to pay $89.54 out of a $110 diagnostic radiology copay for the ultrasound. This service
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 ultrasound (76705) provided on July 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax (S9999).

You asked the Plan to pay for the sales tax. You say that this should be covered. The Plan denied your request. 
The Plan says sales tax is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ogivri for the enrollee.
You asked the Plan to pre-approve Ogivri. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there is no indication our preferred drug forms would likely be less effective, and/or cause adverse effects for the member.
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 Ogivri. Our reviewer says that Ogivri is not medically reasonable and necessary for the enrollee. The patient has not tried and failed the required drugs, Herceptin (trastuzumab) or Trazimera (trastuzumab-qyyp) or Kanjinti (trastuzumab-anns). There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's condition does not meet step therapy for Ogivri. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ogivri have not been met. Therefore, we decided that the Plan does not have to pre-approve Ogivri for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July
22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 22,
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from January 18,
2021, to February 10, 2021, with diagnosis related group (DRG) 871.
You asked the Plan to pay for the inpatient hospital services. You say that the medical records support the
billing of the principal diagnosis code A41.9 with DRG 871. The Plan denied your request. The Plan says the
medical records do not support the billing of the principal diagnosis code A41.9 with DRG 871.
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 principal diagnosis code, 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 hospital
services. Our reviewer says that the medical records do not support the billing of the principal diagnosis code
A41.9 with DRG 871. Our physician reviewer found the review has determined that the admission was noted
for "Life-Threatening hyponatremia requiring complex sodium correction." Sodium level in the emergency
department (ED) was 114 and at time of discharge within normal range. With treatment consistent as well
"Will give dose of Hydrocortisone and remeasure sodium, if patient does not respond then will treat
presumptively for Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) with salt tabs and
water restriction." While sepsis was documented in a query, other medical record and provider documentation
was unclear and incomplete regarding sepsis as present on admission. The review has determined that the
medical records did not support the billing of the principal diagnosis code A41.9: Sepsis, unspecified organism
with DRG 871.
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 hospital services provided from January 18, 2021, to February 10, 2021, with diagnosis related
group (DRG) 871.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator (k0606) provided July 11,
2021.
You asked the Plan to pay for an automatic external defibrillator. You say that you would like reconsideration
based on the documentation provided. The Plan denied your request. The Plan says services were rendered out
of network 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 did not pre-approve the
item/service at issue. Based on the available documentation, 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 an automatic
external defibrillator (k0606) provided July 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on June 22, 2021.
You asked the Plan to pay for the dental service. You say that since this claim is for preventable assessment of
your teeth condition, it should be covered regardless of the device used for making the assessment. The Plan
denied your request. The Plan says periapical x-ray is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-ray is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-ray
(D0220) provided on June 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93971) provided on August 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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 93971
is a column II code to column I code 93970. 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 services (93971) provided on August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76705) provided October 1, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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 76705 is a column II code to column I code 93976. 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 radiology services (76705) provided October 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors for the enrollee.

You asked the Plan to pre-approve Freestyle Libre 14 day sensors. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.

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 use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 day sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing (SN) services of a registered nurse
(RN) (G0299) and home health care provided in patient's home/residence (Q5001) provide from June 24, 2021,
through July 23, 2021.
You asked the Plan to pay for the home health services. You say that you would like this claim reprocessed.
The Plan denied your request. The Plan says this claim has not been billed correctly in regard to Medicare
coding regulations.
The Plan must follow Medicare rules. Medicare rules say that all Home Health Agencies (HHAs) must submit
a request for anticipated payment (RAP) within 5 calendar days after the start of care date for initial 30-day
periods and within 5 calendar days after the "from date" for each subsequent 30-day period of care, which is set
at 0 percent at the beginning of every 30-day period.
We looked at the file and Medicare rules. Medicare rules. Based on this information, we decided that Medicare
rules for coverage of the direct SN services of a RN and home health care have not been met. Specifically, the
record indicates the RAP was not submitted within 5 days of the from the start of care date, June 24, 2021.
Therefore, we decided that the Plan does not have to pay for the direct skilled nursing (SN) services of a
registered nurse (RN) (G0299) and home health care provided in patient's home/residence (Q5001) provide
from June 24, 2021, through July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0481, 80307) provided on September 9, 2021,
by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was not 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 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 drug testing (G0481, 80307) provided on
September 9, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (78830) provided on May 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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 78830
is a column II code to column I code 79101. 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 services (78830) provided on May 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bystolic for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Bystolic for the enrollee.

Benefits for this 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: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing services provided from May 29, 2021, to June 27,
2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says that the
enrollee did not require/receive any skilled level medical management, nursing, or therapy during that time.
The Plan also says that the care that the enrollee required/received could have been rendered at a lower level of
care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will
stop paying for skilled nursing facility services. The Plan must issue a Notice of Medicare Non-Coverage
(NOMNC) no later than two days before the last covered day. This notice must include a description of the
enrollee's right to an appeal.
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or
more days before May 28, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the
Plan has to pay for the skilled nursing services provided from May 29, 2021, to June 27, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus fee (D1999) provided on July 14, 2021.
You asked the Plan to pay for the coronavirus fee. You say that the contracted periodontist appointments are
too far away. You say that your case is an emergency. You also say that your dentist referred you to the
provider in this case. The Plan denied your request. The Plan says coronavirus fee is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the coronavirus fee is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the coronavirus fee
(D1999) provided on July 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002) provided on July 15, 2021.
You asked the Plan to pay for the arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002). You say that the medical records show the diagnosis code was appropriate and the claim should be reprocessed for payment. The Plan denied your request. The Plan says it is not appropriate to report an unspecified diagnosis code for a procedure code billed with modifier 50.
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 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. The CPT Code Manual definition of code 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). We find that CPT code 20610 and 77002 are not supported in the medical record. Specifically, this claim was billed the diagnosis code M16.11 and CPT code 20610-50. M16.11 indicates that this procedure was unilateral, while modifier 50 indicates that this procedure was bilateral. The diagnosis code is mismatched to the procedure modifier. Of note, CPT code 77002 is an add-on code. Because the primary procedure was denied, 77002 is also denied. Based on this information, we decided that Medicare rules for coverage of the arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002) have not been met. Therefore, we decided that the Plan does not have to pay for the arthrocentesis (20610) and fluoroscopic guidance for needle placement (77002) provided on July 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on July 6, 2021.

You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physical therapy services provided on July 6, 2021.