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

We decided that the Plan does not have to pay for a pharmacogenomic panel provided to the enrollee.

You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says procedures reported together must be both medically reasonable and necessary.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee underwent laboratory testing with an expanded pharmacogenomic panel in an assessment of pain management. In this case, the provided documentation does not indicate a sufficient medical rationale for the ordering the expanded panel as billed. The medical reasonableness and necessity of the requested service is not established. The requested service cannot be recommended.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for a pharmacogenomic panel provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you have been receiving orthotics about twenty-two years. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee will require close supervision along with skilled nursing care including 24-hour availability of a nurse and physician skilled in rehabilitation medicine. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require - or to be able to tolerate - 15 hours per week of rehabilitative services with regular physician evaluation. The enrollee's care 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the critical care evaluation and management.

You asked the Plan to waive the deductible for the critical care evaluation and management. You say that you already paid a different provider so paying this provider would be redundant. The Plan denied your request. The Plan says you have been asked to pay 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 $1000 deductible that applies towards in-network hospital care.

The critical care evaluation and management you asked the Plan to waive the deductible for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible that applies towards in-network inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the critical care evaluation and management. Therefore, we decided that the Plan does not have to waive the deductible for the critical care evaluation and management.

Your complaint that an infectious diseases doctor was not required during your stay 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the dermatology visit you had on July 23, 2020.
You asked the Plan to waive the copayment for the dermatology visit. You say that after this visit (which was to get a diagnosis), you were advised that this dermatologist was no longer in the network. You said that because you could not continue care with this provider, you should not have to pay this copayment. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for visits with a specialist. You have been asked to pay a $40 copayment for the dermatology visit. The dermatology visit falls within the visits with a specialist benefit category. This copayment applies regardless of whether or not you continue treatment with this provider. 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 dermatology visit you had on July 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for Behavioral Health services.

You asked the Plan to pay for Behavioral Health services. You say that the Plan should pay 50% of the claim amount. The Plan denied your request. The Plan says this provider opted out of Medicare therefore the claims were denied appropriately.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for Behavioral Health services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Trelegy Aer Ellipta inhalation medication.
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Trelegy Aer Ellipta inhalation medication.
Benefits for this medication 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for pin retention in addition to restoration (D2951) provided on November 16, 2020.
You asked the Plan to pay for the pin retention. You say that this service was necessary to save your teeth. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for pin retention in addition to restoration (D2951) provided on November 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on October 13, 2020.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you disagree with increase in charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on October 13, 2020. The allowed amount is $745.41 and 20% of that is $149.08. You have been asked to pay the total coinsurance amount of $149.08 for a Medicare Part B drug injection. A Medicare Part B drug injection falls 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 coinsurance for a Medicare Part B drug injection provided on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery with an out-of-network provider.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 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 provider at issue in this case is not a network provider with the Plan. 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 surgery. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found you have a chronic condition. There is no urgent or emergent threat to your health or safety. The plan has indicated that the services are available in-network. The medical necessity has not been established by the documentation provided. The requested service cannot be recommended.

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 surgery have not been met.

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 the surgery. Therefore, we decided that the Plan does not have to pre-approve surgery with an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow injections for the enrollee.

You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this injection is helpful for treatment of the health problem.

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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is an experimental/investigational procedure. Therefore, the request is considered not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve fluid flow injections for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (CPT 99291, CPT 99292) provided to the enrollee on September 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this service is considered appropriate for the diagnosis submitted.
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 the denied codes is: CPT 99291: Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes CPT 99292: Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found in this case, there are no medical records supporting the services documented. Critical care time must be documented to be billed. The requested service cannot be recommended. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (CPT 99291, CPT 99292) provided to the enrollee on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc-One syringe for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says a step therapy exception cannot be granted.

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 the injection. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have bilateral knee pain. A request has been made for Synvisc-One, a Hyaluronic acid injection, to treat the right knee. The health plan requires that other forms of Hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of Hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of Hyaluronic acid injections. There is no documentation as to why these other forms of Hyaluronic acid would not be expected to be safe and effective for the enrollee. Therefore, the requested Synvisc-One is not shown to be currently medically necessary and 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc-One syringe for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) continued care provided from September 12, 2020, to October 1, 2020.
You asked the Plan to pay for the custodial care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled therapy or skilled nursing services on the dates of service.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) continued care provided from September 12, 2020, to October 1, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychiatric diagnostic evaluation provided on April 1, 2019.
You asked the Plan to pay for psychiatric diagnostic evaluation (90971). You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the claim was 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 psychiatric diagnostic evaluation (90971) was not filed until October 7, 2020. 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 psychiatric diagnostic evaluation provided on April 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colposcopy provided by a participating provider on November 17, 2020.
You asked the Plan to waive the copayment for a colposcopy. You say that you think this copayment is way too high. The Plan denied your request. The Plan says the correct copayment has been 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 a $280 copayment for outpatient surgery/outpatient surgery performed in a hospital. You have been asked to pay a $280 copayment for a colposcopy. The procedure that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. A colposcopy falls within the outpatient surgery/outpatient surgery performed in a hospital 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 a colposcopy provided by a participating provider on November 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from December 5, 2019, to December 30, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you cannot afford the charges and feel that the copayment charges are too high. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from December 5, 2019, to December 30, 2019, for a total of 10 outpatient rehabilitation visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 10 (visits) = $400. You have been asked to pay the total copayment amount of $400 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from December 5, 2019, to December 30, 2019.
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 you are developing bed sores and would have better quality of life in the IRF. The Plan denied your request. The Plan says the services are not medically necessary.

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 medically necessary. Our physician reviewer found the records show that you have been receiving home health physical and occupational therapy. You are bed-bound and dependent for activities of daily living. You do not require the intensity of services in an IRF. Specifically, you are not shown to be able to perform 15 hours per week of rehabilitative services with regular physician evaluation.

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.