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

We decided that the Plan does not have to pay for reduction of large breast (19318) provided on June 14, 2021,
by an OON provider.
You asked the Plan to pay for reduction of large breast. You say that this procedure is considered medically
necessary and that this provider constantly strives to maintain compliance with your payers. You also say
services were provided to the member in good faith. The Plan denied your request. The Plan says the provider
and hospital are non-network providers who do not work with the member's health Plan, and the member was
referred by a provider who also does not work with the member's Plan. The Plan also says that the primary care
physician (PCP) did not refer for these services and there was no medical necessity for an out-of-network
provider, such as an urgent or emergency situation documented. The Plan said there is no network deficiency
for these services and alternate network providers were found.
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 reduction of large breast (19318) provided on June
14, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Partially Favorable

You asked the Plan to waive the cost-sharing for Prolia. You say that the coinsurance amounts for these dates
are different and you would like to be reimbursed the difference. The Plan says that the coinsurance amounts
you are being charged are correct.
We decided that the Plan has to waive the cost-sharing for Prolia for date of service November 26, 2019.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information
(such as copayments, deductibles, and coinsurance).
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not submit a copy of the 2019 Evidence of Coverage. Without a
copy of the applicable Evidence of Coverage, we cannot determine whether your contract with the Plan
included any cost-sharing for Medicare Part B prescription drugs that would apply to date of service November
26, 2019. Therefore, the Plan has not shown that its decision to ask you to pay $162.65 coinsurance is correct
or justified according to the plan contract. Therefore, we decided that the Plan has to waive the cost-sharing for
Prolia for date of service November 26, 2019.
We also decided that the Plan does not have to waive the cost-sharing for Prolia for date of service June
17, 2021.
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 20%
coinsurance for Prolia. The allowed amount of this claim is $1,146.10, resulting in a coinsurance amount of
$229.22. Therefore, we decided that the Plan does not have to waive the cost-sharing for Prolia.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity angiography rendered on June 29, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 75710 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation. 

We find that CPT code 75710 is not supported in the medical record. Specifically, there is no documentation of radiological supervision and interpretation of a unilateral extremity angiography. 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 extremity angiography rendered on June 29, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided on
March 18, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the psychotherapy service. You say that your doctor is a hospitalist physician and
depends on the hospital staff to verify eligibility and to obtain proper authorization from patients insurance
company. The Plan denied your request. The Plan says enrollee's must receive their medical services from an
in-network provider with the exception being urgent or emergent services. Non-emergent services with non-
contracted providers require prior authorization before services being rendered.
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 individual psychotherapy services (90832)
provided on March 18, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a push-rim activated power assist device (E0986) for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this needs to be medically necessary for its intended use inside the home.

The Plan follows Medicare rules. Medicare rules say that a push-rim power assist device is covered if the general criteria for a power mobility device are met, and the more specific criteria for the push-rim device are also met. 

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 device. Our reviewer says that the requested device is not medically reasonable or necessary. Our physician reviewer found the requested E0986 is not medically necessary, as it's not required for the enrollee to participate in MRADLs in the home. The push-rim activated power assist device is not medically necessary for the enrollee's functional needs inside the home, as the enrollee was already approved for an ultralight wheelchair (K0005). 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a push-rim activated power assist device (E0986) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit rendered on September 22,
2020.
You asked the Plan to waive the deductible for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the deductible was applied correctly.
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 yearly deductible which applies to your covered medical services.
The item or service you asked the Plan to waive the deductible for falls within the out-of-network Medicare-
covered primary care physician services benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that there is $750 yearly deductible which applies to covered medical services. This
cost sharing is a contractual obligation that had not been met at the time these services were received on
September 22, 2020. The file shows that the enrollee had met $423.33 of the deductible at the time this claim
was processed. Therefore, we decided that the Plan does not have to waive the deductible for the office visit
rendered on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound B-scan provided on January 7, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an ultrasound B-scan is covered for the indications established in the applicable NCD. 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 testing. Our reviewer says that the requested ultrasound B-scan was not medically reasonable and necessary. Our physician reviewer found that the available documentation in the case file does not support that the enrollee in this case had/has a dense cataract which required an ultrasound B-scan. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound B-scan provided on January 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 18, 2021, by an OON
provider.
You asked the Plan to pay for the drug testing. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
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. 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 drug testing provided on May 18, 2021, by an
OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from April 3, 2021, through
April 28, 2021.

You asked the Plan to pay for hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service

Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 

The enrollee ended Medicare Hospice benefits on April 3, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided from April 3, 2021, through April 28, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta 32mg injections (J3304).
You asked the Plan to pre-approve Zilretta. You say that Zilretta is medically necessary. The Plan denied your request. The Plan says that 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 Zilretta. Our reviewer says that coverage criteria has been met. Our physician reviewer found the compendia does not preclude use of the drug more than one time. This drug is supported for use for the enrollee's 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 Zilretta have been met. Therefore, we decided that the Plan has to pre-approve Zilretta 32mg injections (J3304).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walk-in tub (E1310, A9901, and S9999), purchased on
August 2, 2021.
You asked the Plan to pay for a walk-in tub. You say that you need this tub to help you relieve your pain.
Please reconsider this denial. The Plan denied your request. The Plan says this item is not covered by Medicare
or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pay for a walk-in tub (E1310, A9901, and S9999), purchased on August
2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injections (J7321).
You asked the Plan to pre-approve the Supartz injections. You say that Supartz injections are medically necessary. The Plan denied your request. The Plan says a trial of Euflexxa is required before alternatives can be considered.
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 the Supartz injections. Our reviewer says that Supartz is not medically necessary. Our physician reviewer found the record shows no trial of conservative therapy. The record shows no trial of the plan preferred drug or any reason it would be unsafe or ineffective 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 the Supartz injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz injections (J7321).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the abscess drainage (49020) provided on April 2, 2021.
You asked the Plan to pay for the abscess drainage (49020). You say that CPT code 49020 was incorrectly denied, and only partial payment was made. You say that both CPT codes are separately payable as defined by Medicare guidelines and the correct reimbursement should be provided. The Plan denied your request. The Plan says CPT code 49020-XS is considered inclusive to CPT code 43840.
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 49020 is drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open.
We asked our coder 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 abscess drainage (49020). Our reviewer says that this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that CPT code 49020 XS has a bundled relationship with 43840, however, the use of an appropriate modifier is allowed to unbundle the relationship if the medical documentation supports the use of the modifier. The medical records provided do not include sufficient documentation to support the use of a modifier to unbundle service 49020, therefore, no additional payment is allowed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the abscess drainage (49020) have not been met. Therefore, we decided that the Plan does not have to pay for the abscess drainage (49020) provided on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 4, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or
proprietary laboratory analysis CPT code.
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for the lab services provided on August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (93922) provided on September 21, 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 76882 is a column II code to column I code 93922. 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 (93922) provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on August 6, 2021.
You asked the Plan to pay for the acupuncture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, review of the file shows that these acupuncture services were provided by a non-covered provider type. In addition, the provide was not supervised by a Physician, Physician's assistant, or Nurse Practitioner/Clinical Nurse Specialist. Therefore, we decided that the Plan does not have to pay for the acupuncture services provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 11, 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 80157, 80177, 80201, 80162, 80159, and 80173 are 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.
We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 not supported in the medical record.
Specifically, the records report a discrepancy between the specimen type collected and the billed codes. 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 laboratory services rendered on March 11,
2021.