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

We decided that the Plan does not have to pay an additional amount for an unspecified preventive procedure 
(D1999) and screening of a patient (D0190) provided on April 26, 2021. 
 
You asked the Plan to pay an additional amount for an unspecified preventive procedure and screening of a 
patient. You say that you had to change providers because your previous provider opted out of your Plan. You 
visited a new provider, and the provider did not want previous results from another dentist, the new provider 
wanted their own evaluation and complete x-rays. The Plan denied your request. The Plan says there is no 
coverage for an unspecified preventive procedures and screening of a patient. 
 
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 an additional 
amount for an unspecified preventive procedure (D1999) and screening of a patient (D0190) provided on April 
26, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does not have to waive the copayment for the administration provided on April 30, 2021.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection and to waive the copayment for the administration. You say that you disagree with the charges because you were never charged this much in the past. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. Your contract with the Plan also clearly says that you must pay a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received a Medicare Part B drug on April 30, 2021. The total allowed amount is $881.46 and 20% of that is $176.29. You received the administration of a Medicare Part B drug at an outpatient hospital facility on April 30, 2021. Therefore, you are responsible to pay the allowed amount of $58.86. The total amount you owe is: $235.15. You have been asked to pay the total amount of $235.15 for a Medicare Part B drug injection and the administration. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs benefit category. The administration of a Medicare Part B drug falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection and does not have to waive the copayment for the administration provided on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81206, 81210, 81235, 81275, 81276, 81292, 
81295, 81298, 81301, 81317, 81401, 81194, 81309) provided March 22, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 
81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, 81194, 81309 and 81445 
have a bundled relationship. 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 lab services (81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 
81317, 81401, 81194, 81309) provided March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on May 19, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on May 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on June 16, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on June 16, 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 Freestyle Libre continuous glucose monitoring (CGM) 
system. 
 
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) system. You say 
that the enrollee has a hard time communicating if they are not feeling well. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for the requested device. 
 
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 perform blood 
glucose testing at least four times per day. Based on this information, we decided that Medicare rules for 
coverage of a Freestyle Libre continuous glucose monitoring (CGM) system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring (CGM) 
system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan represented by code 93976 provided on
June 23, 2021.
You asked the Plan to pay for code 93976. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, we have confirmed that code 93976 is a column II code to column I code 76856. 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 duplex scan represented by code 93976 provided on June 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on October 14, 2020.
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapy services has not been met. Specifically, the billing provider is a nurse practitioner. As such, therapy services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for the therapy services provided on October 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on May 10, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as 
services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the 
qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for the therapy services provided on May 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D3330, D0220) provided May 26, 2021.
You asked the Plan to pay for the dental services. You say that the dental services should be covered in full. The Plan denied your request. The Plan says the benefit was exhausted at the time the services were provided.
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 benefit was exhausted. The $224 billed to the member was in excess of the $1,400 benefit. Therefore, we decided that the Plan does not have to pay for dental services (D3330, D0220) provided May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (80307) rendered by the out-of-network (OON) 
provider on January 15, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the drug test (80307) rendered by the out-of-network (OON) provider on January 15, 
2021.
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 enrollee requires inpatient rehabilitation and
close physician supervision. The Plan denied your request. The Plan says the denial of authorization or IRF
service is correct.
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multidisciplinary rehabilitation program. There is not a reasonable expectation that the enrollee
will be able to fully participate in - and benefit from - the intensive rehabilitation therapy program provided in
an 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: 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 if you do not go to rehabilitation you fear you will
not regain complete independence. The Plan denied your request. The Plan says the denial of authorization for
IRF service is correct.
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 based upon your current high level of function you do not require an intensive,
complex, multidisciplinary approach to daily therapy. You need physical therapy and occupational therapy in
an alternate low-intensity setting. Your rehabilitation needs can be safely met in another setting such as a
skilled nursing facility.
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 waive the copayment for acupuncture visits provided on
May 10, 2021, and May 24, 2021.
You asked the Plan to waive the copayment for acupuncture visits. The Plan denied your request. The Plan says the copayment applies to the services.
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 $10 copayment for Acupuncture for chronic low back pain. You have been asked to pay a $10 copayment for acupuncture visits. Acupuncture visits falls within the Acupuncture 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 acupuncture visits provided on May 10, 2021, and May 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve a total electric hospital bed. You say that the item is necessary. The Plan
denied your request. The Plan says the requested item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed (E0265, E0266,
E0296, and E0297) is not covered; the height adjustment feature is a convenience feature.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a total electric hospital bed have not been met. Therefore, we decided that the Plan does not have
to pre-approve a total electric hospital bed (E0265).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Stelara.
You asked the Plan to pre-approve Stelara. You say that the requested Stelara is medically necessary. The Plan
denied your request. The Plan says that the enrollee must try and fail two of the following: Humira, Rinvoq,
Skyrizi, Actemra, Cosentyx, Otezla, Xeljanz, Xeljanz XR, Orencia, and Enbrel.
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 Stelara. Our reviewer says that the
requested Stelara is medically necessary. Our physician reviewer found of the health plan's step therapy
alternatives only Humira and Enbrel have a medically accepted indication for treatment of Crohn's disease.
Both of these agents carry warnings with regard to increased risk of malignant melanoma which would pose a
risk to this enrollee with his prior history of melanoma. Stelara only carries a warning regarding non-melanoma
skin cancer and appears to be a safer alternative 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 Stelara have been met. Therefore, we decided that the Plan has to pre-approve
Stelara.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation.
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed other
alternative therapies. The Plan denied your request. The Plan says there is a lack of peer-reviewed literature for
the use of radiofrequency ablation for chronic knee pain.
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 the requested services. Our physician
reviewer found that the enrollee has bilateral osteoarthritis of the knees. She has tried physical therapy, steroid
injections, viscosupplementation, and opiates without sustained relief. The requested treatment is considered
experimental/investigational at this time and is the subject of ongoing clinical trials. Therefore, the request is
considered not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve genicular radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone length studies (77073), x-ray exam of the knee; 4 or more views (73564), the hospital outpatient clinic visit (G0463), arthrocentesis, aspiration and/or injection of a major joint or bursa (20610), and the triamcinolone acetonide injections (J3301 x 2) rendered by the out-of-network (OON) provider on April 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 bone length studies (77073), x-ray exam of the knee; 4 or more views (73564), the hospital outpatient clinic visit (G0463), arthrocentesis, aspiration and/or injection of a major joint or bursa (20610), and the triamcinolone acetonide injections (J3301 x 2) rendered by the out-of-network (OON) provider on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen supplies received on August 31, 2020.
You asked the Plan to pay for the oxygen supplies. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says you did not meet criteria for the items received.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Oxygen supplies are only covered for certain indications. The documentation does not support that a blood gas study was performed or that alternative treatment measures have been tried or considered and deemed clinically ineffective. Therefore, we decided that the Plan does not have to pay for the oxygen supplies received on August 31, 2020.