Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on April 15, 2021 to May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the behavioral health 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 received were neither emergent nor urgent and prior authorization was not obtained to seek 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 behavioral health services provided on April 15, 2021 to May 5, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift received on December 13, 2020.
You asked the Plan to pay for a stair lift. You say that you would like to be reimbursed for this item. The Plan denied your request. The Plan says the item received is not covered.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair lift received on December 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the crown (D2750) provided on April 19, 2021 by an OON provider.
You asked the Plan to pay more for the crown. You say that the paperwork says the Plan will pay 50% but only 20% of your bill was paid. The Plan denied your request. The Plan says this service was rendered by an OON provider.
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, you are responsible for a $100 deductible and a 50% coinsurance for a crown. You are also responsible for the difference between the billed amount and allowed amount for the service received OON. Therefore, we decided that the Plan does not have to pay more for the crown (D2750) provided on April 19, 2021 by an OON provider.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the COVID testing U0003. We decided that the Plan does not have to pay for the other pathogen testing.

You asked the Plan to pay for the COVID testing U0003. You say that this is medically necessary. The Plan says that it was determined that this testing as done for screening purposes.

We decided that the Plan has to pay for the COVID testing U0003.

The Plan follows Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating physician. 

In this case, the order in the file shows the intent for testing of a respiratory pathogen panel and COVID-19 testing. The Plan agreed to pay the pathogen panel, but payment must also be made for the COVID test as this is clearly ordered. Therefore, we decided that the Plan has to pay for the COVID testing U0003.

We also decided that the Plan does not have to pay for the other pathogen testing.

The Plan follows Medicare rules. Medicare rules say that lab testing may be covered when ordered by a treating physician. 

The order does not document the intent to perform testing for the other specific pathogens described by the remaining codes. Therefore, we decided that the Plan does not have to pay for the other pathogen testing.

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 neuromuscular stimulator (E0745) provided on May 9, 2021.
You asked the Plan to pay for a neuromuscular stimulator. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that Neuromuscular Electrical Stimulation (NMES) to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy.
We looked at the file and Medicare rules. The records do not indicate that the enrollee has disuse atrophy and that the nerve supply to the muscle is intact. Based on this information, we decided that Medicare rules for coverage of a neuromuscular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on May 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

You asked the Plan to pre-approve Synvisc-One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Synvisc-One. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knee. The documentation does not support that the enrollee has tried and failed Monovisc and Orthovisc. The documentation does not outline contraindications or reasons these medications were not considered. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group three power wheelchair.
You asked the Plan to pre-approve a group three power wheelchair. You say that you would benefit from a power wheelchair. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on June 7, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. The Plan denied your request. The Plan says these services cannot be covered for being received OON.
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, you are responsible for 100% of the cost for dental services received by an OON provider. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis provided on June 7, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the monitored anesthesia care (MAC) provided for an upper endoscopy procedure provided on February 11, 2021.
You asked the Plan to pay for the MAC services. You say that this should be paid. The Plan denied your request. The Plan says diagnosis code Z01.818 is not appropriate for this procedure.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. In this case, the diagnosis code for this claim Z01.818, defined as Encounter for other preprocedural examination. This diagnosis code on its own does not provide sufficient information to support the billing of this service.
No medical records were submitted to show that this is an appropriate diagnosis code for this encounter. Therefore, we decided that the Plan does not have to pay for the monitored anesthesia care (MAC) provided for an upper endoscopy procedure provided on February 11, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided in the home on March 25, 2020.
You asked the Plan to pay for the PT services. You say that this is correctly billed and must be paid. The Plan denied your request. The Plan says this was not billed using a valid code.
The Plan must follow Medicare rules. Medicare rules say that when an NPP bills for the services of a physical therapist, there must be direct supervision, in that the NPP must be physically present. This is required even if the therapist is allowed to perform the services without supervision. In this case, a nurse practitioner is billing for the services provided by this physical therapist but was not present in the enrollee's home. These services cannot be paid to the NPP in this situation. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided in the home on March 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha.
You asked the Plan to pre-approve Repatha. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 Repatha.
Benefits for Repatha 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) to be provided by an out-of-network (OON) provider at the in-network benefit level.

You asked the Plan to pre-approve IMRT. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) to be provided by an out-of-network (OON) provider at the in-network benefit level.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 12, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. 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. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on March 12, 2020 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 blood pressure monitor.
You asked the Plan to pre-approve a blood pressure monitor. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve a blood pressure monitor.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services represented by code 99285 provided on December 2, 2020.
You asked the Plan to pay for code 99285. 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 supported as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 2 units of CPT code 99285 are not supported in the medical record. The medical record only supports 1 unit of CPT code 99285. Based on this information, we decided that Medicare rules for coverage of code 99285-CS have not been met.
Therefore, we decided that the Plan does not have to pay for the emergency room services represented by code 99285 provided on December 2, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve radiopharmaceutical localization of tumor (identified with code 78803).

You asked the Plan to pre-approve radiopharmaceutical localization of tumor. You say that the enrollee has a history of chronic systolic heart failure. The Plan denied your request. The Plan says that the requested services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 radiopharmaceutical localization of tumor. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic systolic heart failure. The record indicates that both kappa and lambda light chains as well as the kappa/lambda ratio are elevated. Echocardiogram is technically deficient and cannot determine left ventricular cavitary size. Therefore, the enrollee meets criteria for the requested service. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiopharmaceutical localization of tumor have been met. Therefore, we decided that the Plan has to pre-approve radiopharmaceutical localization of tumor (identified with code 78803).

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care provided on May 25, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the initial observation care. You say that the provider rendered the service in good faith that the in-network facility would obtain the authorization. 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the initial observation care provided on May 25, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the interpretation of the x-ray of the left shoulder provided on January 29, 2021, billed with code 73030-26-LT.
You asked the Plan to pay for the x-ray interpretation. You say that this should be paid. The Plan denied your request. The Plan says that the records show that this procedure was performed only once, and that payment has already been made for this. This claim is a duplicate and cannot be reimbursed.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to support its denial by providing evidence that there is a paid claim for code 73030-26-LT. Without a copy of a remittance showing payment was made to this provider for this service, the denial is not supported. Therefore, we decided that the Plan has to pay for the interpretation of the x-ray of the left shoulder provided on January 29, 2021, billed with code 73030-26-LT.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radical excision services coded 25115 provided on
October 8, 2020.

You asked the Plan to pay for the radical excision services. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

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 25115 is radical excision of bursa, synovia of wrist, or
forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors.

We find that CPT code 25115 is not supported in the medical record. Specifically, the operative report did not include documentation of a radical excision of bursa, synovia of wrist, or forearm tendon sheaths of the flexors (tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); therefore, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the radical excision services have not been met. Therefore, we decided that the Plan does not have to pay for the radical excision services coded 25115 provided on October 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Cystoscopy (52000) provided on March 23, 2021.
You asked the Plan to waive the copayment for the Cystoscopy (52000). You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a surgical procedure in an outpatient hospital facility on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $150 copayment for Outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a Cystoscopy in an outpatient hospital facility on March 23, 2021. You have been asked to pay a $150 copayment for the Cystoscopy (52000). The Cystoscopy (52000) falls within the Outpatient surgery 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 Cystoscopy (52000) provided on March 23, 2021.