Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation services provided from October 30, 2020, through November 13, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation services. You say that you did not receive speech/language therapy. The Plan denied your request. The Plan says the copayment was 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 $325 copayment per day, days 1-6 for each Medicare-covered hospital admission/stay. You have been asked to pay a total of $1,950 ($325 copayment x 6 days = $1,950) for the inpatient rehabilitation services. This service falls within the Inpatient hospital care 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 inpatient rehabilitation services provided from October 30, 2020, through November 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have fallen and want to prevent this from happening again. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair glide provided on March 30, 2021.

You asked the Plan to pay for a stair glide. You say that this equipment is necessary for you to reach the handicap accessible restroom in the upstairs of your home. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. 

While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pay for a stair glide provided on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement procedures provided from January 4, 2021, to February 26, 2021.
You asked the Plan to waive the copayments for outpatient surgery visits. You say that this is a huge difference in charge for the same services you previously received, and these were not hospital visits. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $250 copayment for each hospital visit for outpatient surgery. These visits were for surgical services performed at an outpatient hospital facility; therefore, the outpatient hospital surgery copayment applies to each visit. There were 7 visits, resulting in a total copayment amount of $1,750. You have been asked to pay $250 copayment for each outpatient surgery visit. Outpatient surgery visits fall within the Outpatient Surgery and Other Medical 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 copayments for wound debridement procedures provided from January 4, 2021, to February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the VistaSeq Hereditary Cancer Panel for the enrollee.

You asked the Plan to pre-approve the panel. You say that this is medically necessary. The Plan denied your request. The Plan says multigene panels 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 panel. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found diffuse large cell lymphoma does not put the enrollee at risk for hereditary cancer. This test is not used as a screening for risk of malignancy. 

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 panel have not been met. Therefore, we decided that the Plan does not have to pre-approve the VistaSeq Hereditary Cancer Panel for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ketorolac injections (J1885, 96372).
You asked the Plan to pre-approve ketorolac injections. You say that you have been on this medication for five years. The Plan denied your request. The Plan says this is only approved for short term use.
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 ketorolac injections. Our reviewer says that the requested use of ketorolac injections is not supported. Our physician reviewer found the medical record states that you have chronic low back pain and one year of shoulder pain. This medicine is only used for short-term pain. The review has determined that the requested use of Ketorolac is not Food and Drug Administration (FDA)-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ketorolac injections have not been met. Therefore, we decided that the Plan does not have to pre-approve ketorolac injections (J1885, 96372).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance guided focused ultrasound (MRgFUS).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRgFUS is covered when specific criteria are met. 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 not medically necessary. Our physician reviewer found you have a diagnosis of essential tremor. You have declined surgery and tried increased dosing of medications, but your symptoms are worsening. There is no clear documentation of the severity of your tremors and no clinical indication as to why surgery would not be able to be performed. The documents to not support that the criteria for coverage are met; therefore, the MRgFUS is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance guided focused ultrasound (MRgFUS).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pulmonary vein isolation procedure provided on January 25, 2021.
You asked the Plan to waive the copayment for the pulmonary vein isolation procedure. You say that this is a large amount to pay for an outpatient procedure. You say this should not be billed as outpatient because you stayed at the hospital for 12 hours. 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 $400 copayment for outpatient surgery in an outpatient hospital facility. You have been asked to pay a $400 copayment for the pulmonary vein isolation procedure. The pulmonary vein isolation procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows you were considered an outpatient.
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 pulmonary vein isolation procedure provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on January 26, 2021 to January 29, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the services at issue are office visits billed with code 99201. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on January 26, 2021 to January 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on December 14, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray rendered on December 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided October 13, 2019 to October 19, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that per your insurance, hospital stays in network requires a daily copay of $300 per night, which you paid and there should not be any further payment required of you. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $300 copayment each day for days 1-5 for Medicare covered hospital care for Inpatient hospital care. You have been asked to pay $1500 ($300 x 5 days) for the inpatient stay. The inpatient stay falls within the Inpatient hospital care 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 inpatient hospital stay provided October 13, 2019 to October 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
You asked the Plan to pre-approve Gelsyn-3 (J7328) Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg. You say that the enrollee is not ready to consider surgery and interested in viscosupplementation. The Plan denied your request. The Plan says the enrollee does not have any stated contraindications to Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc One.
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 Gelsyn-3 (J7328) Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg. Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has not trialed a viscosupplemental treatment such as Visco-3, Gel-One, Orthovisc, Synvisc or Synvisc-One. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gelsyn-3 is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 (J7328) Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (81479) provided on May 6, 2021.
You asked the Plan to pay for Guardant360 testing. 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 follows Medicare rules. Medicare rules say that that Guardant360 remains covered for patients for whom tissue-based comprehensive genomic profiling (CGP) is infeasible. 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 Guardant360 testing. Our reviewer says that the requirements for coverage of Guardant360 testing have not been met. Our physician reviewer found the record indicates that the enrollee has Stage IV non-small cell lung cancer as well as concurrent breast cancer. The record indicates that the enrollee may undergo tissue biopsy. The record does not indicate that a biopsy is contraindicated or technically infeasible. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (81479) provided on May 6, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you could safely receive the care you need in another setting, such as the skilled nursing facility where you went.

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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available where you are currently receiving care. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from May 1, 2020, to May 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that SNFs billing on TOB 21x must be billed with a Patient Driven Payment Model (PDPM) revenue code.

We looked at the file and Medicare rules. The documentation does not support the billed PDPM score. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from May 1, 2020, to May 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and diagnostic services rendered on January 15, 2021 to January 27, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid POS code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. The Plan states that once a corrected claim is received from the provider, you will not owe anything for these services. Therefore, we decided that the Plan does not have to pay for the office visits and diagnostic services rendered on January 15, 2021 to January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on March 27, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for office services. You say that your doctor provided medically necessary services to the enrollee, and you expect reimbursement from the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office services provided on March 27, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested prcoedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that published studies do not demonstrate any long-term health outcome advantage with the use of Superion/Vertiflex as an alternative to standard surgical treatment. The device is considered experimental/investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).