Persius/hicric huggingface dataset:
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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have 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 that you were admitted to an acute care hospital for osteomyelitis of the right foot. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued hemodialysis services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the continued OON dialysis services. You say that the enrollee has been a patient at this facility for many years and should be allowed to continue with this provider. The Plan denied your request. The Plan says a temporary authorization for 24 visits has been approved in order to allow the enrollee time to transfer care to a network facility. No further visits beyond the 24 will be covered OON.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve continued hemodialysis services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on December 8, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that you were told that you would only owe a $20 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $150 copayment for a colonoscopy. A colonoscopy 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 for a colonoscopy provided on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on November 24, 2020.
You asked the Plan to waive the copay for the services provided. You say that your copay should only be $40. The Plan denied your request. The Plan says you are responsible for the specialist copay.
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 copay for each covered visit in an outpatient location with a specialist. You have been asked to pay a $40 copay for the specialist services provided. The services fall within the physician 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 copay for the specialist office visit provided on November 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 genetic testing provided on December 15, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on September 24, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because the service was provided with no adequate time to obtain prior authorization. The Plan denied your request. The Plan says prior authorization is required for the service at issue.
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 the psychotherapy services (90832) provided on September 24, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an electrocardiogram (93000) and a
specialist office visit (99214) on November 3, 2020, and an ultrasound of the heart (93306) on November 19,
2020.
You asked the Plan to waive the copayments for an electrocardiogram, a specialist office visit, and a heart
ultrasound. You say that the Plan's computer system has been giving your providers incorrect information
about your benefits. The Plan denied your request. The Plan says the correct copayments were 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 $100
copayment for each Medicare-covered radiological diagnostic service, not including x-rays; a $20 copayment
for Medicare-covered non-radiological diagnostic services; and a $30 copayment for services obtained from a
specialist.
You have been asked to pay a $100 copayment for a heart ultrasound. A heart ultrasound falls within the
"Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. You have also been asked to
pay a $14.48 copayment for an electrocardiogram. An electrocardiogram falls within the "Outpatient
Diagnostic Tests and Therapeutic Services and Supplies" benefit category. You have been asked to pay less
than or equal to the correct amount based on your contract with the Plan. Finally, you have been asked to pay a
$30 copayment for a specialist office visit. A specialist office visit falls within the "Physician/Practitioner
Services, Including Doctor's Office Visits" benefit category. You have been asked to pay the correct amount
based on your contract with the Plan. These copayments are 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 an electrocardiogram (93000)
and a specialist office visit (99214) on November 3, 2020, and an ultrasound of the heart (93306) on November
19, 2020.
Your complaint about the quality of the Plan's customer service is not a valid appeal for medical coverage.
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to
make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided on
September 21, 2020, by an OON provider.
You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly
reflect the medical necessity for the services rendered. Please process the enclosed documents at the earliest
and reprocess the claim for payment. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. Nonemergent
services with non-contracted providers require prior authorization before services being rendered.
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 individual psychotherapy services (90837)
provided on September 21, 2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan rendered on January 5, 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 diagnosis code is not valid.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid diagnosis code. 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 positron emission tomography (PET) scan rendered on January 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer.
You asked the Plan to pre-approve the Vertiflex Interspinous Spacer. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says this service is experimental.
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 Vertiflex Interspinous Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is considered experimental and more research is needed to show its safety and efficacy. 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 Vertiflex Interspinous Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Interspinous Spacer.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Evenity.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 enrollee has had multiple low trauma fractures. She has been intolerant to other therapies, including teriparatide and alendronate. The documentation indicates that alternatives of Prolia and Zolendronic acid are not appropriate for the enrollee due to the high risk of fractures and failure of other therapies. The requested Evenity is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 at the time of discharge from the hospital the enrollee had stabilized medically. The enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. The enrollee was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. The enrollee did not have any parental medication, complex wound care or nutrition given via a feeding tube. The enrollee was medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function was at or near their baseline and the enrollee could have received further services at a lower level of care as their needs were mainly custodial in nature. Admission to a SNF for inpatient skilled care was 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided February 21, 2020.
You asked the Plan to pay for the intraoperative EEG. You say that your services were ordered by the enrollee's in network surgeon as a surgical requirement and were provided in an in network facility that has established your services as the standard of care for the enrollee's surgical procedure. The Plan denied your request. The Plan says the clinical value and effectiveness of an intraopertive EEG in the setting of lumbar fusion have not been demonstrated in the peer reviewed literature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intraoperative EEG have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided February 21, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee's T-scores support the need for this drug. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the records do not show that the enrollee's condition indicates Prolia or that the enrollee has a contraindication or unresponsiveness to oral osteoporosis agents.
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 Prolia. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Prolia. Our physician reviewer found Medicare-approved drug compendia indicate that Prolia improved bone mineral density from baseline compared with placebo. In this case, the enrollee has osteoporosis. The enrollee has lumbar T-scores of -2.6 at L2 and -3.4 at L1. The requested use is a medically accepted indication as defined by Medicare rules. The documentation indicates that the enrollee's dual-energy X-Ray absorptiometry (DEXA) scan results have worsened. The requested use of Prolia is safe and effective for 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve use of Prolia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on October 28, 2020.
You asked the Plan to waive the coinsurance for DME and related supplies. You say that you were told that DME was 100% covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for DME and related supplies. You received DME and related supplies on October 28, 2020. The total allowed amount is $1,459.90 and 20% of that is $291.98. You have been asked to pay the total coinsurance amount of $291.98 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies provided on October 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the extended ophthalmoscopy rendered on November 11, 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 procedure code 92201 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 92201 and 92250. Code 92201 is a column II code with a modifier indicator of 1 when billed with column I code 92250. Code 92201 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the extended ophthalmoscopy rendered on November 11, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided by a participating provider on November 21, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you did not pay this much the last time. You say that you are a senior citizen and cannot afford this. The Plan denied your request. The Plan says the correct copayments have 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services. You have been asked to pay a $110 copayment for each ultrasound. The total amount you are being asked to pay is $220 ($110 x 2 ultrasounds = $220). The correct copayment has been applied to the services provided. An ultrasound falls within the outpatient diagnostic tests/radiological diagnostic 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 ultrasound provided by a participating provider on November 21, 2020.