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

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.
You asked the Plan to pre-approve a Superion interspinous spacer. 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 a Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not indicate that the enrollee is not indicted for operative treatment at more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Superion interspinous spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for a health club membership 
(S9970) for the 2020 benefit allowance. 

You asked the Plan to reimburse you an additional amount for a health club membership. You say that this 
should be covered because the health club billed you incorrectly as you opted to freeze your membership due to 
traveling out of area to get a lower rate but were charged at full price for November and December 2019. The 
health club offered a credit for this mistake for February and March 2020. You also say you have tried to get a 
letter of attestation for the billing errors but now the facility has gone bankrupt, and staff is no longer 
answering the phone. The Plan denied your request. The Plan says you provided a receipt that shows a payment 
of $76.44. The remaining balance is denied for lack of proof of payment. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. To obtain this reimbursement 
please submit a Wellness Allowance reimbursement form along with proof of payment and any additional 
information outlined on the form. 
 
The Plan's rules for coverage of gym benefits have not been met. The records show the Plan only received a 
receipt for $76.44 to show proof of payment. The records also show that proof of payment for the remaining 
balance was not received. Therefore, we decided that the Plan does not have to reimburse you an additional 
amount for a health club membership (S9970) for the 2020 benefit allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis, aspiration and/or
injection (20610) provided May 11, 2021.
You asked the Plan to waive the copayment for the outpatient services. You say that please take care of the
following charges. You do not owe these. In the last six months you have spent hours on the phone trying to
correct the bills you are receiving. The Plan denied your request. The Plan says the claim was processed with
the correct copayment applied.
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 $275
copayment for Medicare covered outpatient hospital and observations services. You have been asked to pay $234.56 for the outpatient services. Since the allowed amount is less than the
copayment amount, you are responsible for the lesser amount. the outpatient services fall within the Outpatient
hospital services 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 arthrocentesis,
aspiration and/or injection (20610) provided May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on
March 6, 2021.
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration
because this service was rendered in good faith and meets professionally recognized standards of care. The
Plan denied your request. The Plan says this claim is a duplicate.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be an exact duplicate are rejected and do not have appeal rights.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the subsequent nursing facility care have not been met. Specifically, the record indicates that this is
a duplicate claim. The documentation submitted includes evidence that a claim was paid for the same member,
provider, date of service and CPT code. Therefore, we decided that the Plan does not have to pay for the
subsequent nursing facility care (99309) provided on March 6, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits and 11 additional home health physical therapy visits.
You asked the Plan to pre-approve additional home health services. You say that home health care skilled services continue to be medically necessary. The Plan denied your request. The Plan says the criteria for continued home health care have not been met.
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 additional home health services. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found the documentation does not support that the member requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The member does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not medically 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 additional home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 additional home health skilled nursing visits and 11 additional home health physical therapy visits
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the direct skilled nursing services of an RN (G0299) and direct skilled nursing services of an LPN (G0300) provided from April 15, 2020, to April 30, 2020.
You asked the Plan to pay for the direct skilled nursing services of an RN and LPN. You say that the enrollee needed assistance and the services you provided to him. The Plan denied your request. The Plan says the providers contracted/negotiated rate is expired or not on file.
The Plan must follow Medicare rules. Medicare rules say that denial code 147 will be issued if the provider's rate is not on file with CMS. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the direct skilled nursing services of an RN and LPN have not been met. The record shows that CMS and the Plan do not have the provider's rate on file.
Therefore, we decided that the Plan does not have to pay for the direct skilled nursing services of an RN (G0299) and direct skilled nursing services of an LPN (G0300) provided from April 15, 2020, to April 30, 2020.
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 these services are medically necessary. 
The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and do not 
require transfer to an LTACH. 
 
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. You are 
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are 
not available at the acute care hospital where you are currently receiving care. There are no services available 
at the LTACH that you require that are not available at the health care setting being offered by the health plan. 
Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for services received on February 2, 2021, February 16, 2021, and April 20, 2021.
You asked the Plan to waive the cost share for the office visit (99204, 99214), x-ray (73610), tissue removal (26111), injection (J0702) and incision (26055). You say that the services should be covered by the Plan. The Plan denied your request. The Plan says the services are covered and you were charged the copayments and deductibles 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 $30 copayment for specialist physician services. You can find this information on page 4-41 of the Plan's 2021 Evidence of Coverage. Your contract says you have a 20% coinsurance for Medicare Part B drugs. You can find this information on page 4-27 of the Plan's 2021 Evidence of Coverage. Your contract also says you have
a $750 deductible for covered medical services. You can find this information on page 4-2 of the Plan's 2021 Evidence of Coverage. You have been asked to pay $30 copayments for physician services, 20% coinsurance for the injection, and a $750 deductible for x-ray, tissue removal, and incision. 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 cost share for services received on February 2, 2021, February 16, 2021, and April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for ophthalmology services provided from March 9,
2020, to May 29, 2020, while out of the country.
You asked the Plan to reimburse you for office consult (99242), Scanning computerized ophthalmic diagnostic
imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), Fluorescein
angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral (92235),
Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization (65450). You say that
you saw an ophthalmologist while outside of the USA and were told it was critical that you see a retinal
specialist as soon as possible. The Plan denied your request. The Plan says the out of area services were not
urgent or emergent.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care.
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 reimburse you for the services. Our reviewer says
that the out-of-area service was not emergent or urgent. Our physician reviewer found the provided records do
not establish that the requested services were either emergent or urgent, defined as an unforeseen illness or
condition. The elements of the coverage criteria are not satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of office consult (99242), Scanning computerized ophthalmic diagnostic imaging,
posterior segment, with interpretation and report, unilateral or bilateral; retina (92134), Fluorescein
angiography (includes multiframe imaging) with interpretation and report, unilateral or bilateral (92235),
Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization (65450) have not been
met. Therefore, we decided that the Plan does not have to reimburse you for ophthalmology services provided
from March 9, 2020, to May 29, 2020, while out of the country.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs provided on September 8, 2020.
You asked the Plan to pay for the drugs. The Plan denied your request. The Plan says the services are not
covered. The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted
using a compounded drug, not otherwise classified (NOC) code.
We looked at the file and Medicare rules. The multiple drug codes reported on this claim refer to a pre-filled
compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not
otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
Based on this information, we decided that Medicare rules for coverage of the drugs have not been met.
Therefore, we decided that the Plan does not have to pay for the drugs provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the darbepoetin alfa injection rendered on May 26, 2021.
You asked the Plan to waive the coinsurance for these services. You say that you are being charged too much. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for Medicare Part B prescription drugs.
Review of the file shows that you received a darbepoetin alfa injection on May 26, 2021. You have been asked to pay a 20% coinsurance for these services. These services fall within the Medicare Part B prescription drugs 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 coinsurance for the darbepoetin alfa injection rendered on May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Qvar Rediha. 
 
You asked the Plan to pre-approve Qvar Rediha. You say that the medication is necessary. The Plan denied 
your request. The Plan says your 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 Qvar Rediha.  
 
Benefits for Qvar Rediha 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided May 20, 2021.
You asked the Plan to pay for the dental consultation. You say that the service was medically necessary because you were having problems with your dentures. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on May 28, 2021, by an 
out-of-network provider. 
 
You asked the Plan to pay for the home health services. You say that the enrollee needed to be seen for 
multiple chronic conditions and medication refill. The Plan denied your request. The Plan says the provider did 
not obtain 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 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 home health services provided on May 28, 2021, by an out-
of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ViviGen Allograft.
You asked the Plan to pre-approve ViviGen Allograft. 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 ViviGen Allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Vivigen allograft remains experimental for use in spinal surgery. More research is needed to show safety and effiacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ViviGen Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve ViviGen Allograft.
Appeal type: Drugs
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare Part B generally does not pay for drugs that are usually self-administered by the patients who take them. Examples of self-administered drugs are drugs in pill form and those used for self-injection. The only exceptions are: 1. blood-clotting factors; 2. drugs used in immunosuppressive therapy; 3. erythropoietin for dialysis patients; 4. osteoporosis drugs for certain homebound patients; 5. certain oral cancer drugs; 6. oral anti-emetics used in certain situations; 7. drugs treated as supplies during an outpatient hospital procedure; and 8. drugs required for the effective use of durable medical equipment. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50, 50.2, 50.5, and 110.3.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound provided on May 11, 2021. You asked the Plan to pay for ultrasound, abdominal (76705). You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code.
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 ultrasound, abdominal (76705) has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 ultrasound provided on May 11, 2021.