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

We decided that the Plan does not have to waive the deductible for the EKG (CPT code(s): 93005 and G0463) provided on April 9, 2021, by an in-network provider.
You asked the Plan to waive the deductible for the EKG. You say that the EKG was performed at the doctor's office and this was not an outpatient procedure. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Review of the file show that you received an EKG on April 9, 2021. Your EOC does not show that radiological services are covered under a physician office visit. Furthermore, radiological services are included in your deductible. At the time of services rendered you had not met your $750 deductible; therefore, you have been asked to pay $108.45 for the services to apply to your deductible. This cost sharing is a contractual obligation that had not been met at the time the EKG was received on April 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the EKG (CPT code(s): 93005 and G0463) provided on April 9, 2021, by an in-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you require max assist post-surgery. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for coronary artery bypass grafting. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sterile needles (A4215) and electrodes (A4556) used during diagnostic testing provided on June 28, 2020.
You asked the Plan to pay for the needles and electrodes. You say that the services are medically necessary and should be covered. The Plan denied your request. The Plan says these are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Code A4215 has a status indicator of "X" in the Physician Fee Schedule. This means that it is statutorily excluded from payment as part of physician services. Code A4556 has a status indicator of "P" in the Physician Fee Schedule. This means that "if the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident." As other physician services were paid, this payment for this item is bundled with payment for those services. Based on this information, we decided that Medicare rules for coverage of the needles and electrodes have not been met. Therefore, we decided that the Plan does not have to pay for the sterile needles (A4215) and electrodes (A4556) used during diagnostic testing provided on June 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 16, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a
covered service.

The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or
more pathogens are non-covered.

We looked at the file and Medicare rules. The records show that 6 or more pathogens were tested in the panel
in this case. Based on this information, we decided that Medicare rules for coverage of the lab services have not
been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 16,
2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Inqovi.
You asked the Plan to pre-approve Inqovi. You say that the medication is necessary. The Plan denied your
request. The Plan says the enrollee has a medical only policy which does not include Part D prescription
coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Inqovi.
Benefits for Inqovi may be available under Medicare Part D. Contact the Plan that administers Part D benefits
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for telehealth anticoagulation management
(CPT code 93793) provided from February 2, 2021, through April 6, 2021.
You asked the Plan to waive the copayment for the services. You say that this is for your anticoagulant
management for your medication and you should not have to pay copayments for phone calls for your
management program. The Plan denied your request. The Plan says the claim was processed accordingly with
your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance).
Review of the file show that you received telehealth anticoagulation management from a specialist on February
2, 2021, through April 6, 2021. The Medicare-allowed amount for the telehealth specialist services is less than
the set $40 copayment; therefore, you have been asked to pay the lesser amount of $11.68 for February 2, 2021,
$11.68 for March 2, 2021, and $11.34 for April 6, 2021. The health plan contract says that enrollees must pay a
$10 copayment for each PCP visit for Medicare-covered services and a $40 copayment for each physician
specialist visit for Medicare-covered services. Medicare-covered telehealth is covered at the same
PCP/specialist copayment as in-person visit for your plan. 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 telehealth anticoagulation management (CPT code 93793) provided from February 2, 2021, through April
6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on review of the available records, you do not meet the CMS coverage criteria for an admission to an SNF. Admission to SNF is not reasonable and not medically necessary. At the current level of function, you do not require daily skilled therapies in an inpatient setting. Documentation does not support the need for an admission to an SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve the additional physical therapy visits. You say that physical therapy will
help with the enrollee's mobility. You say that the enrollee is continuing to ambulate slowly and remain
hesitant to bear weight on the left lower extremity. You say that the enrollee's left wrist and arm feel stiff. The
Plan denied your request. The Plan says the requested physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not
generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by
the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, that the services can be safely
and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has
been instructed in and is compliant in a home exercise program. The requested services are not part of a
maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
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 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the member's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says that you can safely receive the rehabilitation services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for Clostridium difficile
colitis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization.
You asked the Plan to pre-approve prostate artery embolization. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 prostate artery embolization. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is considered an experimental technique to treat symptomatic benign prostatic hyperplasia (BPH). Very limited studies have demonstrated possible short-term safety and efficacy. The most recent guidelines do not recommend this procedure outside of a clinical trial 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 prostate artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve prostate artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for fitting of spectacles, except for aphakia; bifocal (CPT code 92341) provided to the enrollee on March 26, 2021.
You asked the Plan to pay for the services. You say that the nursing facility asked the provider to examine the enrollee and the enrollee did not have any input in choosing who would be their optometrist. The Plan denied your request. The Plan says this is an administrative determination for lack of medical documentation and is not based on clinical criteria for medical necessity. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The Plan made multiple requests to obtain medical records without success. There is not enough information provided to verify the services were necessary or meet the criteria for coverage. Therefore, we decided that the Plan does not have to pay for fitting of spectacles, except for aphakia; bifocal (CPT code 92341) provided to the enrollee on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by an out-of-network provider on January 26, 2021, to February 5, 2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not agree with this provider being out-of-network. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 copayment per day for days 1-7. There is a $0 copayment for additional days for inpatient hospital care.
You have been asked to pay a $275 copayment per day for days 1-7. There is a $0 copayment for additional days for an inpatient hospital stay. The total amount you are being asked to pay is $1,925 ($275 x 7 days = $1,925). The same copayment amount applies to both in-network and out-of-network providers. An inpatient hospital 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 an inpatient hospital stay provided by an out-of-network provider on January 26, 2021, to February 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device.
You asked the Plan to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 insertion of an interlaminar/interspinous process stabilization/distraction device. 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 enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multi-level disease including mild spinal stenosis at L2-L3 and L4-L5, the levels requested for treatment. The record does not indicate that the enrollee requires operative treatment at more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of an interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig (A9282) purchased on April 7, 2021.

You asked the Plan to pay for the wig. You say that you were told to purchase this wig and to submit the receipt for reimbursement. The Plan denied your request. The Plan says wigs and hair prosthesis are not covered by Medicare or by the Plan. The Plan reviewed call records and found that you had already purchased the wig prior to contacting the Plan, and that you were directed to purchase this item by an out-of-network provider who is not contracted with the Plan.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would
provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig (A9282) purchased on April 7, 2021.