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

We decided that the Plan does not have to waive the copayments for the inpatient skilled nursing facility care
and the ambulance transportation services provided from January 12, 2021, through February 28, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $20 copayment each day for days 1-20 and a $150 copayment for days 21-34 for a stay at a skilled
nursing facility.
Additionally, enrollees pay a $250 copayment for each one-way Medicare-covered ambulance trip. Enrollees
also pay a $250 copayment for transportation between inpatient facilities.
The enrollee has been asked to pay $734.67 ($250 + $250 + $234.67) for the Medicare-covered ambulance
transportation trips provided on January 12, 2021, January 18, 2021, and February 9, 2021, which is less than
the applicable copayments for these services. Additionally, the enrollee has been asked to pay $120
($20 copayment x 6 days) for the inpatient skilled nursing facility care provided from January 12, 2021,
through January 18, 2021. The enrollee has also been asked to pay $1,180 ($20 copayment x 14 days=$280)
for days 7-20 and ($150 copay x 6 days=$900) for days 21-26 for inpatient skilled nursing facility care
provided from February 9, 2021, through February 28, 2021. 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 copayments for the inpatient skilled nursing facility care and the ambulance transportation services
provided from January 12, 2021, through February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on April 5, 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 77002 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 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). 

We find that CPT code 77002 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a primary procedure code. 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 fluoroscopic guidance rendered on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim is missing a condition code.
The Plan must follow Medicare rules. Medicare rules say that institutional providers billing clinical trial service(s) must report ICD-9 diagnosis code V70.7 if ICD-9 is applicable or, if ICD-10-CM is applicable, ICD-10 diagnosis code Z006 in either the primary or secondary position and a condition code 30 regardless of whether all services are related to the clinical trial or not. We looked at the file and Medicare rules. In this case, the enrollee is in a clinical trial, and inpatient services rendered while in a clinical trial require the provider to report condition code 30. A condition code is not reported on the claim. Based on this information, we decided that Medicare rules for coverage of the services not been met. Therefore, we decided that the Plan does not have to pay for the services provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the temporomandibular joint specialist services
provided from July 7, 2020, to September 3, 2020 by an out-of-network provider.
You asked the Plan to reimburse you for the temporomandibular joint specialist services. You say that you
were unsatisfied with the Plan's specialist, so you researched and found a reputable specialist. The Plan denied
your request. The Plan says you did not request prior authorization as required.
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 reimburse you 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
reimburse you for these items/services. Therefore, we decided that the Plan does not have to reimburse you for
the temporomandibular joint specialist services provided from July 7, 2020, to September 3, 2020 by an out-ofnetwork
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a dermatology
consultation.
You asked the Plan to pre-approve the referral. You say that it is unreasonable to suggest a provider which is
almost an hour away. The Plan denied your request. The Plan says there are network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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. he 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
an out-of-network referral for a dermatology consultation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on January 21, 2021.
You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied
your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically
necessary when used for SelectMDx.
We looked at the file and Medicare rules. The testing at issue is not covered.Based on this information, we
decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that
the Plan does not have to pay for SelectMDx testing (81479) provided on January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the Plan's medical benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Benefits for Prolia 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Euflexxa injection (J7323) provided on May 12, 2021.
You asked the Plan to waive the copayment for the injection services. You say that you received an injection in your knees on 05/05/21 and the copay was $52.26. You received the same injection on 05/12/21 and the copay was $72.51. The doctor said the procedure was the same and the copay should be as well. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
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% for each Medicare covered Part B drug obtained in a provider's office or outpatient setting. You have been asked to pay $72.51 for the injection services. The records show that for date of service 05/05/2021, the provider billed that 1 unit of Euflexxa injection was provided so your coinsurance was $20.26 with your copay of $32.00 totaling $52.26. For date of service 2 units of Euflexxa injection was provided, so the coinsurance amount was $40.51 with your copay of $32.00 totaling $72.51. The injection services fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the Euflexxa injection (J7323) provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a peripherally implanted nerve stimulator.
You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555). You say that these services are medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare for your condition.
The Plan must follow Medicare rules. Medicare rules say that no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation unless there has been psychological screening.
We looked at the file and Medicare rules. There is no psychological evaluation in the case file. Based on this information, we decided that Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) have not been met. Therefore, we decided that the Plan does not have to pre-approve a peripherally implanted nerve stimulator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 20, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 is not supported in the medical record. Specifically, the documentation shows that the enrollee was inpatient for this date of service. This code was billed with place of service 22 (outpatient). This means that this code was billed with an inappropriate place of service.
Based on this information, we decided that Medicare rules for coverage of the x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter placement for coronary angiography on February 16, 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 the services are not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 93459 (catheter placement in coronary artery[s] for coronary angiography) and 92928 (percutaneous transcatheter placement of intracoronary stent[s]).

Code 93459 is a column II code with a modifier indicator of 1 when billed with column I code 92928. Code 93459 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the catheter placement for coronary angiography on February 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ofev 150 mg capsule.
You asked the Plan to pre-approve Ofev. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the Plan's 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 Ofev 150 mg capsule.
Benefits for Ofev 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 7, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were not aware of the charges that would occur by declining the ambulance transport to the hospital. You also say that you are on a fixed income and cannot afford to pay for this. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
 
The ambulance company did not provide transport services on June 7, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on June 7, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 7 additional home health skilled nursing visits.
You asked the Plan to pre-approve 7 additional home health skilled nursing visits. You say that this care is medically necessary. The Plan denied your request. The Plan says the criteria for home health nursing services are not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 7 additional home health skilled nursing visits. Our reviewer says that home health skilled nursing services are not medically reasonable and necessary. Our physician reviewer found based on the documentation provided, you do not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy, new/changed meds). As such, the requested home health skilled nursing services are not shown to be medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 7 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (71045) provided on April 27, 2021.

You asked the Plan to pay for an x-ray. You say that this was provided in an appropriate location. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that a physician/practitioner/supplier furnishing services to a patient who is a registered inpatient, shall, at a minimum, report the inpatient hospital place of service code 21 irrespective of the setting where the patient actually receives the face-to-face encounter. 

We looked at the file and Medicare rules. The enrollee was an inpatient at the time of service, but this claim was not billed with an inpatient place of service code. Based on this information, we decided that Medicare rules for coverage of an x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the ophthalmology visit and Avastin
injection you received on April 13, 2021, and the ophthalmology visit and ophthalmic ultrasound you had on
April 16, 2021.
You asked the Plan to waive the cost sharing for the ophthalmology visits, the Avastin injection, and the
ophthalmic ultrasound. You say that you want to appeal these copayments because the eye doctor suggested
that you have an injection before your cataract surgery. You said that this injection made you blind. The Plan
denied your request. The Plan says you were charged this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30
copayment for visits with a specialist, 20% coinsurance for Medicare Part B drugs, and a $30 copayment for
diagnostic tests with a specialist.
You have been asked to pay a $30 copayment for each of the ophthalmology visits, 20% coinsurance for the
Avastin injection, and a $30 copayment for the ophthalmic ultrasound. The ophthalmology visits fall within the
visits with a specialist benefit category. The Avastin injection is a Medicare Part B drug and the ultrasound is a
diagnostic test you received in a specialist's office. These cost sharing amounts apply regardless of the outcome
of the services. This means that you have been asked to pay the correct amount based on your contract with the
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore,
we decided that the Plan does not have to waive the cost sharing for the ophthalmology visit and Avastin
injection you received on April 13, 2021, and the ophthalmology visit and ophthalmic ultrasound you had on
April 16, 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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 on the provided documentation, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's needs can be met at a lower level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for SNF care provided on January 4, 2021.
You asked the Plan to waive the coinsurance for SNF care. You say that you had to leave the SNF due to horrible service. The Plan denied your request. The Plan says the correct coinsurance was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 10% coinsurance for Medicare-covered SNF stays, days 1 to 100. You have been asked to pay $49.89, or 10% of the Medicare-allowed charge of $498.90, for SNF care. SNF care falls within the "Skilled nursing facility (SNF) care" 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 SNF care provided on January 4, 2021. Your complaint about being charged for SNF care you regard as having been substandard is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.