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

We decided that the Plan does not have to waive the copayment forbunion surgery provided on June 28, 2019.You asked the Plan to waive the copayment forbunion surgery. You say that a pin needed to be taken out after surgery. You say that it was very painful.The Plan denied your request. The Plan says the copayment applied 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 $150 copayment for Medicare-covered surgery or each day of observation provided to you at an outpatient hospital setting or ambulatory surgical center. You have been asked to pay a $150 copayment for bunion surgery. Bunion surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 forbunion surgery provided on June 28, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 10, 2019.You asked the Plan to pay for the train of four monitoring. You say that you would like reconsideration as the services rendered were medically necessary. The Plan denied your request. The Plan says train of four is considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.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 find that CPT code 95999 is not supported in the record. Specifically, the payment for train of four monitoring is included in the payment for the approved neuromonitoring services. Based on this information, we decided that Medicare rules for coverage of the train of four monitoring have not been met. Therefore, we decided that the Plan does not have to pay for train of four monitoring (95999) provided on January 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on May 3, 2019.You asked the Plan to waive the copayment for the medical eye exam. You say that this was your routine eye exam and you should not be charged a copayment. The Plan denied your request. The Plan says you have been charged 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 $40 copayment per visit for Medicare-covered exams to diagnose and treat diseasesof the eye, including an annual glaucoma screening for members at high risk. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows a diagnosis of age-related cataracts which makes the eye exam medical in nature.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 forthe medical eye exam provided on May 3, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 13, 2019 and October 1, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rulessay 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 Plandid not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 13, 2019 and October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrencia for the enrollee.You asked the Plan to pre-approveOrencia. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee does not meet the step therapy requirements.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 thatit 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 Orencia. Our reviewer says that Orencia is not medically reasonable and necessary for the enrollee in this case. Orencia is being requested for the treatment of rheumatoid arthritis. The enrollee has not trialed Remicade, Inflectra or Simponi Aria. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria forOrencia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orencia have not been met.Therefore, we decided that the Plan does not have to pre-approveOrenciafor the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Comprehensive Inherited Cancer Gene test for the enrollee.You asked the Plan to pre-approvethetest. You say that this is medically necessary.The Plan denied your request. The Plan says there is no indication that your doctor is actually treating the enrollee, nor managing any medical conditions.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 test. Our reviewer says that the requested test not considered medically reasonable and necessary in this case. Our physician reviewer found the case file contains no clinical records which supportthat Comprehensive Inherited Cancer Gene testing is medically reasonable and necessary for the enrollee in this case. There is no indication that the enrollee has recurrent, relapsed, refractory, metastatic, or advanced cancer. There is no documentation as to how this testing will impact the management of the enrollee's condition.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 test have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Comprehensive Inherited Cancer Gene test for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from June13, 2019, to June 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from June 13, 2019, to June 18, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forMagnetic Resonance Imaging (MRI) of the upper extremity (73221) provided on September 13, 2019.You asked the Plan to waive the copayment forthe MRI. You say that the copayment should be waived because the MRI did not yield useful results.The Plan denied your request. The Plan says the correct cost sharing 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 a $225 copayment for Diagnostic Radiology. You have been asked to pay a $225 copayment forthe MRI. The MRI falls within the Diagnostic Radiology 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 forMagnetic Resonance Imaging (MRI) of the upper extremity (73221) provided on September 13, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 10, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).You asked the Plan to pre-approvebone marrow aspiration (20939). You say that the requested bone marrow aspiration is medically necessary.The Plan denied your request. The Plan says the requested bone marrow aspiration is not medically 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 pre-approve bone marrow aspiration (20939). Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee is with worsening neck pain associated with radiculopathy. Bone marrow aspiration is experimental in spine fusion. More research is needed. The requested bone marrow aspiration is not medically reasonable or necessary 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 bone marrow aspiration (20939) have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration (20939).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCT scan of the chest for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 denyingthe request to pre-approve the services. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the medical necessity of a followup CT in regard to a pulmonary nodule is not in the chart hence the medical necessity of the requested followup CT of the chest is not established.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 Plandoes not haveto pre-approveCT scan of the chest for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forCPT codes 95908, 95886, and 95999 provided on January 30, 2019.You asked the Plan to pay forCPT codes 95908, 95886, and 95999. 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.In this case, the CPT Code Manual definition of code 95908 is Nerve conduction studies; 3-4 studies.Weasked 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 CPT codes 95908, 95886, and 95999. Our reviewer says that the medical records do nosupport the billing of CPT code 95908. Our physician reviewer found according to the CPT manual, 95908 represents performance of nerve conduction studies (NCS). In this case the procedure reports provided for review did not specify that a NCS was performed. Rather the reports stated that pedicle screw stimulation was performed using triggered EMG. A nerve conduction study generally involves the application of a stimulus to a nerve and then a measurement from the surface in which latency and amplitude are captured. In this case the only service performed was pedicle screw stimulation--a procedure which did not involve measurement of latency and amplitude (as is commonly and customarily done in an NCS). For these reasons it can be said that the records provided for review did not support the billed CPT code of 95908.Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare rules say that CPT Code 95886 is a Type 1 add-on code and must be reported with a proper Primary Code. In this case, CPT Code 95886 was billed with a Primary Code that is not payable per Medicare guidelines above. CPT Code 95886 is not eligible for payment in this case.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 95999 is unlisted neurological or neuromuscular diagnostic procedure. We find that CPT code 95999 is not supported in the medical record.Specifically, the record shows that train of four testing was performed and this is not the appropriate code for this service. Per Medicare guidelines, it is inappropriate to bill unlisted neurological or neuromuscular diagnostic CPT codes for train of four monitoring. There is no separate code for train of four monitoring.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 95908, 95886, and 95999 have notbeen met.Therefore, we decided that the Plan does not have to pay forCPT codes 95908, 95886, and 95999 provided on January 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout of network cancer treatment. You asked the Plan to pre-approveout of network providers. You say that you believe you should be allowed to be treated by the requested provider.The Plan denied your request. The Plansays the requested provider is not in 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approveout of network cancer treatment.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that the enrollee needs to get back to his condition prior to the hospital stay.The Plan denied your request. The Plan says the enrollee is medically stable and doesn't require supervision by an inpatient rehab physician three times a week.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's current level of function is ambulating 30 feet times 2 with a rolling walker with minimal assist, supine to sit with moderate assist, sit to supine with standby assist, transfers with moderate assist, and toilet transfers with moderate assist. The enrollee is currently medically stable. There is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. While he may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient services (50590, 52332, C1758, C1769, J0696, J1100, J1940, J2250, J2405, J3010, and J7120) provided on June 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forout-of-network services. You say that you were not told these services required authorization.The Plan denied your request. The Plan says out-of-network services require 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 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. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe outpatient services (50590, 52332, C1758, C1769, J0696, J1100, J1940, J2250, J2405, J3010, and J7120) provided on June 6, 2019 by an out of network (OON)provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea custom orthotic insert.You asked the Plan to pre-approvethe orthotic insert. You say that you cannot wear one insert in one shoe and not the other, it throws off your balance.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-approvea customorthotic insert.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.You asked the Planto pre-approvethe SNF admission. You say that the medical records provided support the necessity of the services in dispute.The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage. The enrollee's needs can be met with home-care or services in an office or clinic.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Ourphysician reviewer found there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approvethe skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to providea Group 2 power wheelchair and accessories.You asked the Plan to providea Group 2 power wheelchair and accessories. You say that the enrollee needs a Group 2 power wheelchair and accessories.The Plan denied your request. The Plan says the documentation shows the enrollee ambulates with a cane and does not show symptoms that limit ambulation for MRADLs.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not contain a face-to-face examination. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to providea Group 2 power wheelchair and accessories.