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

We decided that the Plan does not have to waive the copayments for telehealth specialist visits provided from 
October 22, 2020, to December 18, 2020. 
 
You asked the Plan to waive the copayments for telehealth specialist visits. You say that you disagree with the 
charges because these were telehealth visits and you should not owe a copayment. 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 $35 
copayment for telehealth specialist visits. You had telehealth specialist visits from October 22, 2020, to December 18, 2020, for a total of 3 visits. 
Therefore, you are responsible to pay a $35 copayment per each visit. The total amount you owe is: $35 
(copayment) x 3 (telehealth specialist visits) = $105.  
 
You have been asked to pay the total copayment amount of $105 for telehealth specialist visits. Telehealth 
specialist visits fall within the physician/practitioner services, including doctor's office visits 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 telehealth specialist visits provided from October 22, 2020, 
to December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on February 15, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON) provider on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor (BPM).

You asked the Plan to pre-approve the BPM. You say that you do not feel that the OTC item offered by the Plan is sufficient to meet your needs. The Plan denied your request.

The Plan says you have coverage for an OTC BPM under your supplemental benefit. Your request for coverage of a different type of BPM is 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. Your Plan also offers an OTC benefit which would cover an automatic home BPM if purchased.

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. Your Plan offers an additional benefit which would cover an OTC BPM. Although you may require a more accurate device, such a device is not covered by Medicare or under the terms of the OTC supplemental benefit. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor (BPM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494). 
 
You asked the Plan to pre-approve facet joint injections. You say that this should be covered. The Plan denied 
your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say therapeutic facet joint procedures or radiofrequency 
ablation procedures are considered medically reasonable and necessary when the patient has had two (2) 
medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent 
minimum of 80% relief of primary (index) pain (with the duration of relief being consistent with the agent 
used).  
 
We looked at the file and Medicare rules. The submitted medical records do not show that you have had two 
diagnostic procedures that provided at least 80% relief. The records indicate that previous procedures did not 
provide any pain relief. Based on this information, we decided that Medicare rules for coverage of facet joint 
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint 
injections (64493, 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint (CPT 64625).
You asked the Plan to pre-approve the radiofrequency ablation. You say that you are appealing the denial of coverage for radiofrequency ablation to the sacroiliac joint for pain management. The Plan denied your request. The Plan says radiofrequency ablation to the sacroiliac joint for pain management is experimental, investigational or unproven. There is limited data supporting the safety and efficacy of this treatment.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac joint (CPT 64625).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-L4 and L4-L5 is 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray you had at an outpatient 
hospital facility on April 20, 2021. 
 
You asked the Plan to waive the copayment for the chest x-ray. You say that you had this x-ray at a simple 
radiology center, so this should cost less than $45. The Plan denied your request. The Plan says you were 
charged this copayment correctly.  The Plan says that because the allowed amount for this x-ray ($79.11) is less 
than your copayment obligation, you are responsible for the full allowed 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 $105 
copayment for basic radiology at an outpatient hospital facility.  
 
You have been asked to pay a $105 copayment for the chest x-ray. The facility where you had this service and 
that billed this service is considered an outpatient hospital facility. 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 chest x-ray you had at an outpatient hospital facility on April 20, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GRANIX (J1447).
You asked the Plan to pre-approve GRANIX (J1447). You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not medically necessary.
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 GRANIX (J1447). Our reviewer says that the drug is not medically necessary. Our physician reviewer found a trial of drug Neupogen (filgrastim), Nivestym (filgrastim-aafi), and Zarxio (filgrastim-sndz) is required before the Plan will approve the requested drug. In this case, the patient has not tried and failed the required drugs and there is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of GRANIX (J1447) have not been met. Specifically, the enrollee has not met the step therapy requirement for the requested drug. Therefore, we decided that the Plan does not have to pre-approve GRANIX (J1447).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bariatric services (99214).

You asked the Plan to pre-approve the bariatric services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that obesity screening and therapy to promote sustained weight loss is ONLY covered in the primary care setting. 

We looked at the file and Medicare rules. The services being requested are not provided in the primary care setting. The requested provider is not contracted to provide the enrollee's primary care services. Based on this information, we decided that Medicare rules for coverage of the bariatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve bariatric services (99214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that the compression stockings give you more strength to move around. The Plan denied your request. The Plan says the gradient compression stockings are wound care items which are non-covered under the surgical dressing benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve a therapeutic CGM. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthroscopic subacromial decompression (29826) for the enrollee.
You asked the Plan to pre-approve arthroscopic subacromial decompression (29826). You say that this surgery is medically necessary. The Plan denied your request. The Plan says that Medicare coverage criteria are not met.
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 arthroscopic subacromial decompression (29826). Our reviewer says that medical necessity has been established in this case. Our physician reviewer found the enrollee was being treated for impingement syndrome of the left shoulder. The enrollee presented with progressive weakness in the left shoulder for the last year and became painful in the last 2-3 months. The pain is located mostly anterior. The pain is sharp and travels down the arm past the elbow. The enrollee reports catching as well as occasional popping in the shoulder. Symptoms are aggravated by reaching, pulling, pushing, work at or above shoulder height. The pain does wake him from sleep. Exam of the left shoulder reveals forward flexion 180, external rotation 50, and internal rotation L4. Rotator cuff strength is 4+/5 in supraspinatus. There is tenderness to palpation in the critical zone. Hawkins's, Neer's, cross body, and O'Brien's are positive. MRI demonstrated moderate acromioclavicular joint osteoarthritis, inferiorly directed osteophytes at the acromioclavicular joint, which abut the supraspinatus tendon at the myotendinous junction. Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities has been documented. Therefore, the request for arthroscopic subacromial decompression (CPT 29826) is medically reasonable and 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 arthroscopic subacromial decompression (29826) have been met. Therefore, we decided that the Plan has to pre-approve arthroscopic subacromial decompression (29826) for the enrollee.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on April 14, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were admitted within 24 hours, so this copayment should be waived. The Plan denied your request. The Plan says you were charged this copayment correctly because you were not admitted as an inpatient.
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 $110 copayment for emergency room visits.
You have been asked to pay a $110 copayment for the ER visit. The medical records from this visit explicitly state that you were not admitted as an inaptient, but rather kept in observation. Your Evidence of Coverage says that the ER copayment applies if you are kept in observation. 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. Please note that this decision is limited to the ER copayment. If you wish to appeal any other charges, please contact your Plan directly to start that process. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on April 14, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on May 1, 2020.
You asked the Plan to pay for therapeutic exercises. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on May 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve wheelchair side guards (K0108). 
 
You asked the Plan to pre-approve the side guards. You say that the side guards are medically necessary. The 
Plan denied your request. The Plan says this feature is not primarily medical in nature and is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair side guards (K0108).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you have been seeing this doctor for years, and your Plan suddenly stopped approval of your pain clinic. The Plan denied your request. The Plan says the provider is out-of-network
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 the office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a podiatrist on March 16, 2021.

You asked the Plan to waive the copayment for the podiatry visit. You say that you don't understand why the Plan isn't paying anything for these services as they were medically necessary. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the charged amount ($26.00) is less than your copayment obligation, you are responsible for the full 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 $45 copayment for podiatry services. 

You have been asked to pay a $45 copayment for the podiatry visit. 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 visit you had with a podiatrist on March 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar spinal fusion.
You asked the Plan to pre-approve the lumbar spinal fusion.. You say that you would like reconsideration because you are in a great deal of pain in your neck and back. The Plan denied your request. The Plan says you must quit smoking 6 weeks prior to this procedure.
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 lumbar spinal fusion.. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate that the member is a smoker. Smoking is a contraindication for the requested procedure. 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 lumbar spinal fusion. have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal fusion.