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

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99334) rendered by the out-of-network (OON) provider on September 8, 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 for the evaluation and management of an established patient (99334) rendered by the out-of-network (OON) provider on September 8, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound debridement (11043, 11044, 11042) provided on
September 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for wound debridement. You say that the service was rendered due to medical
necessity and the patient care was provided as an urgent request from the Medical Director/SNF/PCP to avoid
wound complications such as: deterioration, amputation, infection and or hospitalization. You also say that due
to the patient medical condition your physician provided care in good will without requesting an authorization
to avoid delay in care, which could result in medical complications. The Plan denied your request. The Plan
says the services were rendered by a non-contracted provider and there is no referral letter from an in-network
physician. The Plan also says that there are contracted providers in the health Plan. The Plan also says that the
services were not medically necessary.
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 wound debridement (11043, 11044, 11042)
provided on September 15, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hernia repair on claim number 82021214004083 provided on March 15, 2021.  You asked the Plan to pay for the hernia repair. You say that you didn't realize your insurance was out-of-network and not accepted. You say that you are unable to pay the full amount of this bill due to financial hardship and want help with this situation. The Plan denied your request. The Plan says the claim denied as a duplicate of the previous claim that processed at 50% coinsurance.   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 hernia repair for the duplicate claim have not been met. You are not being held responsible for payment on the duplicate claim, you are only responsible for the 50% coinsurance on claim number 820211230463602. Contact the Plan if you are being balance billed by the provider for the duplicate claim. Therefore, we decided that the Plan does not have to pay for the hernia repair on claim number 82021214004083 provided on March 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab service provided on July 15, 2020.  You asked the Plan to pay for the services provided. You say that you waited for the correct diagnosis code to be advised from the referring physician. The Plan denied your request. The Plan says the claim was processed correctly.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a clean claim for the services was not filed until August 6, 2021. This means that more than one calendar year from the date of service had passed before the claim was filed. Therefore, we decided that the Plan does not have to pay for the lab service provided on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder test (CPT code 0012M) provided to the enrollee on July 21, 2021.  You asked the Plan to pay for the CxBladder test. You say that the claim should be paid. The Plan denied your request. The Plan says your request is not a covered benefit because after review, the test is considered non-covered.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder test have not been met. The rules say non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for the CxBladder test (CPT code 0012M) provided to the enrollee on July 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99233) provided on September 18, 2020.
You asked the Plan to pay for hospital care. You say that the enrollee did not provide the insurance information
for some time after services were rendered, and the claim was submitted as soon as this information was
available. The Plan denied your request. The Plan says this claim was submitted more than one year after
services were provided and is therefore untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for hospital care was not filed until September 29, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for hospital care (99233) provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a needle electromyography provided on August 10, 2020.  You asked the Plan to waive the copayment for the needle electromyography. You say that the Plan letter says all copayments are waived for this time period. The Plan denied your request. The Plan says the enrollee has been charged the correct cost sharing 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $30 copayment for non-radiological diagnostic services.   The enrollee has been asked to pay a $30 copayment for the needle electromyography. Please note that page 2 of the referenced Plan letter says that lab and diagnostic tests are excluded from the waiver, unless related to COVID-19. The needle electromyography falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a needle electromyography provided on August 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan/Supartz for the enrollee.
You asked the Plan to pre-approve Hyalgan/Supartz. You say that this is medically necessary. The Plan denied your request. The Plan says that records do not show that the enrollee has a specific medical reason why the preferred medicines cannot be used for the enrollee's care.
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 Hyalgan/Supartz. Our reviewer says that Hyalgan/Supartz is not medically reasonable and necessary for the enrollee. The Plan requires a trial of Durolane, Gelsyn-3 and Synvisc/Synvics-One before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Hyalgan/Supartz. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan/Supartz have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan/Supartz for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acute inpatient hospital care after surgery.  You asked the Plan to pre-approve acute inpatient hospital care. You say that this inpatient hospital care following surgery is medically necessary. The Plan denied your request. The Plan says it is not medically necessary for the enrollee to receive inpatient hospital care following the surgery.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is undergoing a planned L4-5 decompressive laminectomy, posterior spinal instrumentation, and fusion. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT codes: 63047, 22612, 22840, and 20936 is not listed on the Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review indicates that the record does not show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care after surgery.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge (CPT code P9604) provided to the enrollee on March 22, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  CPT code P9604 remains not supported. The submitted medical records do not contain enough detail to support travel was performed or the units billed. Sufficient document was not supported, including beginning, and ending travel times and mileage beginning and ending numbers; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge (CPT code P9604) provided to the enrollee on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography of the thorax, diagnostic; without contrast material (71250) rendered by the out-of-network (OON) provider on June 3, 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 or a referral.  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, pre-approved care, and via the Point of Service benefit option.  The provider in this case is not a network provider with the Plan. Although the Plan contract states that an enrollee may obtain services from an out-of-network provider via the Point of Service benefit option, a referral must be submitted by a primary care physician. If the enrollee does not get a referral, they will have to pay the full cost of any services received. The Plan did not pre-approve the service at issue and did not receive a referral from the enrollee's primary care physician. Therefore, we decided that the Plan does not have to pay for the computed tomography of the thorax, diagnostic; without contrast material (71250) rendered by the out-of-network (OON) provider on June 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 15, 2021.  You asked the Plan to pay for the dental service. You say that your previous dentist retired. You also say that this is not your fault. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that the frequency limit has been exceeded.  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 and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a comprehensive oral evaluation that you received on March 3, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on September 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 853.  You asked the Plan to pay for the inpatient hospital services billed with DRG 853. You say that you would like this claim to be reprocessed for the correct reimbursement. The Plan denied your request. The Plan says DRG 853 is not supported as the diagnosis of Sepsis, unspecified organism and Acute and chronic respiratory failure with hypoxia.  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, and secondary diagnosis code, J96.21, defined as Acute and chronic respiratory failure with hypoxia. 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 billed with DRG 853. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found the medical records did not support the billing of Sepsis, unspecified organism and Acute and chronic respiratory failure with hypoxia.   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 billed with diagnosis related group (DRG) code 853.   Please Note: The Plan's decision letter is inappropriately based on a diagnosis code that was not billed on the claim. The diagnosis code that was billed by the provider and reviewed by the Plan's auditor is J96.21.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on August 24, 2021.  You asked the Plan to pay for the services provided. You say that the test has the ability to detect ovarian malignancy. The Plan denied your request. The Plan says the claim was processed correctly.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.  We looked at the file and the rules. The claim shows that the service at issue was billed with diagnosis codes that specified the right side, left side, and unspecified side. The diagnosis codes were not billed correctly. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203) rendered by the out-of-network (OON) provider on February 23, 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 office visit (99203) rendered by the out-of-network (OON) provider on  February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on September 23, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that you feel that the lab service should be included with your annual physical. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $0 copayment for an annual physical. If you receive services that address a medical condition during the same visit, additional cost-sharing may apply.  Your contract with the Plan also clearly says that you must pay a $10 copayment for lab tests that are not FIT tests.   You have been asked to pay a $10 copayment for the laboratory services. The laboratory services fall 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 laboratory services provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Guardian 3 Sensors for use with continuous glucose monitor (A9276).  You asked the Plan to pre-approve the continuous glucose monitor equipment. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this item is not covered per Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit).    We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor equipment have not been met. Specifically, the requested CGM device does not meet the definition of a therapeutic CGM. Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve the Guardian 3 Sensors for use with continuous glucose monitor (A9276).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Oxycontin 15mg tablets.  You asked the Plan to pre-approve Oxycontin. You say that Oxycontin is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  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 Oxycontin 15mg tablets.   Benefits for Oxycontin may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.