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

We decided that the Plan has to pay for outpatient hospital services provided to the enrollee from February 3, 2020 to February 28, 2020.
You asked the Plan to pay for the services. You say that there were line items on this claim that were denied for the CQ modifier, which is the correct modifier and is payable. The Plan denied your request. The Plan says that valid modifiers are required for the claim lines.
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 is "CPT 97530: Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes CPT 97116: Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) CPT 97110:
Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 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 reviewers says that the services at issue in this case were coded correctly. Our physician reviewer found the codes were submitted with a CQ modifier indicating Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant. This claim does meet the criteria for reimbursement. 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 been met. Therefore, we decided that the Plan has to pay for outpatient hospital services provided to the enrollee from February 3, 2020 to February 28, 2020.
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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the neck spine.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs 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 denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the submitted records show that you have a long history of back pain and have a recent history of back painfor two months with associated numbness. The presence of pain and numbness makes evaluation more urgent and MRI is reasonable and indicated. The services are reasonable and medically 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 these services have been met.Therefore, we decided that the Plan has to pre-approvemagnetic resonance imaging (MRI) of the neck spine.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approv eDarzalex for the enrollee.You asked the Plan to pre-approveDarzalex. You say that this is medically necessary.The Plan denied your request. The Plan says that the current documentation we have does not meet the standards for coverage.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Darzalex. Our reviewer says that Darzalex is not medically reasonable and necessary for the enrollee in this case. Darzalex is not FDA-approved for the enrollee's diagnosis. Darzalex is FDA approved for the treatment of multiple myeloma (in combination with dexamethasone and pomalidomide) in adults who have received at least 2 prior therapies, including lenalidomide and a proteasome inhibitor. The enrollee has only received 1 prior line. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for coverage of Darzalex.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darzalex have not been met.Therefore, we decided that the Plan does not have to pre-approveDarzalex for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on December 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 for lab tests provided on December 20, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis (27279). You asked the Plan to pre-approvesacroiliac joint arthrodesis. You say that you need this because you are in a lot of pain.The Plan denied your request. The Plan says the records do not show that you have tried physical therapy.The Plan must follow Medicare rules. Medicare rules say that minimally-invasive surgical (MIS) fusion of the sacroiliac (SI) joint is considered medically necessaryonly when you have had a minimum six months of intensive non-operative treatment that must include medication optimization, activity modification, bracing, and active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program.We looked at the file and Medicare rules. The submitted medical records do not document active therapeutic exercise targeted at the lumbar spine, pelvis, SIJ and hip including a home exercise program.Without this treatment, the criteria for coverage have not been met. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint arthrodesis have not been met.Therefore, we decided that the Plan does not have to pre-approvesacroiliac joint arthrodesis (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the treatment of root canal obstruction (D3331).
You asked the Plan to pre-approve the treatment of root canal obstruction (D3331). You say that you do not understand your benefits. The Plan denied your request. The Plan says the service is not a covered 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 pre-approve the treatment of root canal obstruction (D3331).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says LTACH services are not medically necessary.
The Plan must follow Medicare rules. The rules 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. Our physician reviewer found 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 he is currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, 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-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee has been residing in an assisted
living environment and was diagnosed with a UTI. You say that the enrollee is unable to hold regular
conversations, is wandering, and is not sleeping. You say that there is a concern about the enrollee's rapid
change in status and say that a SNF stay would help her improve. The Plan denied your request. The Plan says
the enrollee does not meet the criteria for coverage of SNF care. The Plan says that the enrollee has not had a
change in function that needs daily skilled therapy services in an inpatient SNF.
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 services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found there are no required skilled nursing
services identified. Our physician reviewer found that the documentation does not support that the enrollee
requires skilled therapy services. Our physician reviewer found that the enrollee does not require the necessary
services on 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 services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services (90791) provided on March 5, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not pre-authorized or emergent.
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 for the outpatient mental health services (90791) provided on March 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the positioning cushion/wedge pillow (E0190).
You asked the Plan to pre-approve the positioning pillow. You say that you do not have the money to pay but this is medically necessary for therapy. Your provider wants your to have this at night and you are disabled. The Plan denied your request. The Plan says this is a convenience item and is not 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 the positioning cushion/wedge pillow (E0190).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0261).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you would like to have the information re-evaluated. The hospital bed is a necessity for the health of the enrollee. The Plan denied your request. The Plan says the requested services have been found to be not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found In this case, the patient does not suffer from significant edema, or impaired mobility. There is no apparent need for immediate/frequent changes in body position. Necessity has not been established. As such, this request is not medically 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 semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0261).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0429) provided December 20, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $220 copayment for Ambulance Services. You have been asked to pay a $220 copayment for the ambulance transport. The ambulance transport falls within the Ambulance 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 an ambulance transport (A0429) provided December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided February 18 to February 27, 2020.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 $285 per day copayment for days 1-7 for Inpatient Hospital Care. You have been asked to pay a $285 per day copayment for days 1-7 for the inpatient hospital care, for a total of $1995. 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 inpatient hospital care provided February 18 to February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer 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 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 for lab work provided on July 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous transluminal angioplasty (PTA).
You asked the Plan to pre-approve the PTA procedure. You say that this should be allowed as it is medically necessary. The Plan denied your request. The Plan says the criteria for this procedure have not been met.
The Plan follows Medicare rules. Medicare rules say that PTA is covered for enrollees at high risk of CEA who are participating in an approved clinical trial. 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 PTA procedure. Our reviewer says that the enrollee does not meet the NCD criteria for the requested service. Our physician reviewer found the enrollee's stenosis is noted to be less than 50% meaning he is not considered high risk for CEA. In addition, this is not being offered as part of a Category B IDE clinical trial. 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 PTA procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous transluminal angioplasty (PTA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions and a consultation to be provided by an oral surgeon.
You asked the Plan to pay for the extractions and consultation. You say that the enrollee needs to go to an oral surgeon due to her Fosamax. The Plan denied your request. The Plan says the enrollee's contract only covers dental services when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.
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 when they are provided by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pay for the two extractions and a consultation to be provided by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the defibrillator and pacemaker surgery provided on March 9, 2020.
You asked the Plan to waive the copayment for the defibrillator and pacemaker surgery. You say that you should not be responsible for the second $250 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 $250 copayment for each in-network ambulatory surgical center visit. You have been asked to pay a $250 copayment for the defibrillator and pacemaker surgery. The defibrillator and pacemaker surgery falls within the "Outpatient surgery, including services provided at hospital 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 for the defibrillator and pacemaker surgery provided on March 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vision services, frames (V2020) purchased on February 14, 2020.You asked the Plan to pay forthe vision services. You say that you feel that using in-network providers did not reduce your out-of-pocket expenses. You chose a provider that was most cost effective.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the services are rendered by an in-network provider.We looked at the file and the Plan's rules. Vision services must be provided by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forthe vision services, frames (V2020) purchased on February 14, 2020.