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

We decided that the Plan does not have to pre-approvea nerve block procedure (64624).You asked the Plan to pre-approvethe nerve block procedure. You say that the service is medically necessary.The Plan denied your request. The Plan says this procedure is experimental and is not covered.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 nerve block procedure. Our reviewersays that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an investigational procedure that is the subject of ongoing clinical trials to determine its role in osteoarthritis therapy. It is considered experimental and is not covered at this time.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 nerve block procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea nerve block procedure (64624).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copaymentfor the magnetic resonance imaging (MRI) scan of the pelvis (72197) and the magnetic resonance imaging (MRI) scan of the abdomen (74183) provided on January 7, 2020 and January 8, 2020.You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has 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). Your contract with the Plan clearly says that you must pay a $75 copayment for Medicare-covered MRI, MRA, and Angiogram at a freestanding provider.You have been asked to pay a $150 copayment ($75 copayment x 2) for the MRI diagnostic scansprovided. 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 adjust the copaymentfor the magnetic resonance imaging (MRI) scan of the pelvis (72197) and the magnetic resonance imaging (MRI) scan of the abdomen (74183) provided on January 7, 2020 and January 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure provided.

You asked the Plan to waive the co payment for the outpatient surgical procedure. 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 an outpatient surgical procedure on the date of service at issue in this appeal. The Plan says that the correct co payment 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 co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 co payment for Medicare-covered outpatient surgery in an outpatient hospital setting or ambulatory surgical center. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an outpatient surgical service. You have been asked to pay a $270.55 co payment for the outpatient surgical procedure, which is less than the contracted $300 copayment amount. The outpatient surgical procedure falls within the Outpatient hospital services 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 outpatient surgical procedure provided.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approveMohs surgery.You asked the Plan to pre-approveMohs surgery. The Plandenied your request. The Plan says that this is not medically necessary.The Plan follows Medicare rules. Medicare rules say that Mohs surgery is covered for the above indications.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 Mohs surgery. Our reviewer says that the requested Mohs surgery is medically reasonable and necessary. Our physician reviewer found that based on the very large size (6cm x 4cm) and ill-defined nature of this tumor, this case falls under indication (B.) of the LCD, Primary Aggressive, Area L may be covered on redetermination if size is greater than or equal to 0.6 cm.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mohs surgery have been met.Therefore, we decided that the Plan has to pre-approveMohs surgery.If the Plandoes 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 doesnot happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenineteen dental extractions, immediate upper and lower dentures, and four alveoloplasty services.You asked the Plan to pre-approvenineteen dental extractions, immediate upper and lower dentures, and four alveoloplasty services. You say that these services are medically necessary.The Plan denied your request. The Plan says these services are not covered.Medicare generally does notcover 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, it covers only one extraction per year, which was previously approved. The other requested items and services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approvenineteen dental extractions, immediate upper and lower dentures, and four alveoloplasty services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services with CPT codes 81407 and 81408 provided on May 23, 2020.You asked the Plan to pay forthe laboratory 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 coveredThe Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The tests at issue in this appeal, the laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes.Therefore, we decided that the Plan does not haveto pay forthe laboratory services with CPT codes 81407 and 81408 provided on May 23, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe x-ray and laboratory services provided on August 19, 2020.You asked the Plan to waive the copayments forthe x-ray and laboratory services. 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 x-ray services and laboratory services on the date of service at issue in this appeal. The Plan says that the correct copayments have 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 $35 copayment per day, per provider, for Medicare-covered x-ray services. The Plan contract also says that enrollees must pay a $20 copayment per day, per provider, for Medicare-covered lab services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received x-ray services and laboratory services on August 19, 2020. You have been asked to pay a $35 copayment for the x-ray services. You have also been asked to pay a $12.47 copayment for the laboratory services, which is less than the contracted $20 copayment amount. The x-ray and laboratory services fall within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amounts based on your contract with the Plan. This cost sharing is a contractual obligation youagreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe x-ray and laboratory services provided on August 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex multidisciplinary approach to daily therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 physician reviewer found that the enrollee was admitted to the acute hospital for falls, rhabdomyolysis and urinary tract infection. His medical conditions are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health skilled nursing services.You asked the Plan to pre-approvehome health nursing services. The Plandenied your request. The Plan says the enrollee does not have recurrent blood draw orders, or skilled wound care.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 home health nursing services. Our physician reviewer found that inthis case, the documentation doesn't support that the enrolleerequires additional skilled nursing services to provide treatment. Shedoes not require additional skilled nursing to effectively provide treatment, care, and/or services in order to improve hercondition, perform a maintenance program to maintain conditions, or prevent deterioration. The enrolleehas been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health nursing services have not been met.Therefore,we decided that the Plan does not have to pre-approvehome health skilled nursing services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.The Plan must follow Medicare rules. Therules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Long term acute care hospitals are certifiedas acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The enrollee is receiving acute hospital care and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe self-administered drugs provided on September 20, 2020.You asked the Plan to pay forthe self-administered drugs. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says Ciprofloxacin and Metronidazole are not covered drugs under your Medicare Part B 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 Plandoes not have to pay forthe self-administered drugs provided on September 20, 2020.Benefits for the self-administered drugsmay be available under Medicare Part D.Contactthe 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 pay forthe medical services provided on April 30, 2019, by an out-of-network (OON) provider.You asked the Plan to pay forthe 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 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 forthe medical services provided on April 30, 2019, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveradiofrequency ablation (64633, 64634).You asked the Plan to pre-approvethe ablation procedure. You say that the procedure is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that no more than two (2) thermal RF sessions will be reimbursed in any rolling 12 month year, involving no more than four (4) joints per session.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 ablation procedure. Our reviewer says that the requested radiofrequency ablation is not medically necessary. Our physician reviewer found the provided documentation states the enrollee received two CRFA sessions in both January and February of 2020, 4 levels each. The request exceeds the maximum limit for a 12 month period and limitof sites (8 requested) per session.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 ablation procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveradiofrequency ablation (64633, 64634).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient therapy services provided from January 1, 2020 to June 12, 2020.
You asked the Plan to waive the copayments for the outpatient therapy services. 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 outpatient therapy services on the dates of service at issue in this appeal. The Plan says that the correct copayments have 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 $40 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient therapy services from January 1, 2020 to June 12, 2020. You have been asked to pay a $40 copayment for each of the outpatient therapy services, with the exception of a $33.47 copayment for the May 24, 2020 date of service, which is less than the contracted $40 copayment amount. The outpatient therapy services fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amounts 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 copayments for the outpatient therapy services provided from January 1, 2020 to June 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe artery x-ray surgical procedure provided on June 29, 2020.You asked the Plan to waive the copayment forthe artery x-ray surgical procedure. 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 an artery x-ray surgical procedure on June 29, 2020.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 $300 copayment for outpatient surgery. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an artery x-ray surgical procedure on June 29, 2020. You have been asked to pay a $300 copayment for the artery x-ray surgical procedure. The artery x-ray surgical procedure falls within the Outpatient hospital services 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 whenyou enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe artery x-ray surgical procedure provided on June 29, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 21, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe 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 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 forthe medical services provided on September 21, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home infusion therapy services with CPT code S9328 provided from July 16, 2020 to August 26, 2020.You asked the Plan to pay forCPT code S9328. 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 providers must report services correctly. Providers must report services with the appropriate CPT code.We looked at the file and Medicare rules. In this case, CPT code S9328 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service.Therefore, we decided that the Plan does not have to pay forthe home infusion therapy services with CPT code S9328 provided from July 16, 2020 to August 26, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 29, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe physician service. You say that the service was medically necessary.The Plan denied your request. The Plan says the provider in this case is out of network. The Plan also says that prior authorization was not obtained before the services were provided.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 forthe medical services provided on June 29, 2020 by an out of network (OON) provider.