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

We decided that the Plan does not have to waive the copayment for the laboratory work provided on December 11, 2020.
You asked the Plan to waive the copayment for the laboratory work. You say that this was preventive laboratory work, and it should be covered. You say you have never paid for laboratory work. 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 $5 copayment for in- and out-of-network Medicare-covered lab services. You have been asked to pay a $5 copayment for the laboratory work. The laboratory work falls within "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. 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 laboratory work provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this request is medically necessary. The Plan denied your request. The Plan says the coverage criteria for a therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injections (J7318).
You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the records show no trial of the plan preferred drugs. The records do not show any reason the plan preferred drugs would be unsafe or ineffective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane injections (J7318).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need to be seen by a rehab doctor three times a week.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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 physician reviewer found that you were admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, in an intensive rehabilitation therapy program. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.

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 services provided by an out-of-network provider on November 15, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a cardiac rhythm monitoring device provided on January 27, 2021.
You asked the Plan to waive the copayment for a cardiac rhythm monitoring device. You say that this was a covered benefit previously and now has a cost-share. The Plan denied your request. The Plan says the copayment you are being charged is 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 a $35 copayment for outpatient diagnostic tests and therapeutic services and supplies.
The EOC confirms that $35 is the required copayment for this service. You have been asked to pay a copayment of $28.46, which is less than the Plan's contracted amount. A cardiac rhythm monitoring device 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. 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 cardiac rhythm monitoring device (93298) provided on January 27, 2021.
Your complaint about the Plan's previous claims processing 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services coded 95886, the nerve conduction studies coded 95908, and the short-latency somatosensory evoked potential study services coded 95938 provided on November 12, 2020.
You asked the Plan to pay for the needle electromyography services, the nerve conduction studies, and the short-latency somatosensory evoked potential study services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 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. We find that CPT codes 95886, 95908, and 95938 are not supported in the medical record. Specifically, the billed place of service (POS) 15 is not supported. The documentation submitted and/or claims data indicate the enrollee received services in a facility setting. Additionally, these codes have a PC/TC Modifier Status of 1
(Diagnostic Tests). Current Procedural Terminology (CPT) codes 95886, 95908, and 95938 are not payable in the facility setting 15 (21,22,23,24). Payment for this service is included in payment to the facility and not separately reimbursable for this provider in this place of service. Based on this information, we decided that Medicare rules for coverage of the needle electromyography services, the nerve conduction studies, and the short-latency somatosensory evoked potential study services have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography services coded 95886, the nerve conduction studies coded 95908, and the short-latency somatosensory evoked potential study services coded 95938 provided on November 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires active and ongoing intervention with a multidisciplinary team. The Plan denied your request. The Plan says the enrollee is not able to participate in the intensive therapies provided in an IRF.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for falls, diarrhea, electrolyte abnormalities and cirrhosis. Her medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. She does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the EMG provided by Shelly Nepa, DO, on February 25, 2020.
You asked the Plan to waive the copayment for the EMG. You say that the tests were unnecessary and are costing a lot of money. You say this is a very difficult time to pay the copayment. 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 $150 copayment for other outpatient diagnostic tests (includes genetic testing).
You have been asked to pay a $150 copayment for the EMG. The EMG 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. 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 EMG provided on February 25, 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 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 surgical treatment of an ankle fracture after a fall. Medical conditions 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. Although you do require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. In conclusion, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lower limb prostheses to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve lower limb prostheses. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be provided by a network provider.

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 lower limb prostheses to be provided 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 cervical epidural steroid injection at C6-C7.

You asked the Plan to pre-approve a cervical epidural steroid injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered for certain indications. 

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 cervical epidural steroid injection. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have chronic neck pain. You had some physical therapy in 2019, but not a full course. You have had prior cervical epidural steroid injections. There is no documentation of other recent conservative therapies. You had Trigger Point injections. The minimal response from prior Epidural Steroid Injections does not meet criteria of the LCD. Therefore, you do not meet criteria for the requested 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 a cervical epidural steroid injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical epidural steroid injection at C6-C7.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on February 7, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 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 laboratory work provided on February 7, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to adjust the copayment for the office visit (99213), tangential biopsy of skin (11102), and the destruction of pre-malignant lesions (17000, 17003) provided on February 10, 2021.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan clearly says that you must pay a $35 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office (as permitted under Medicare rules); consultation, diagnosis, and treatment are covered. The Plan says you must pay a $104.95 copayment for the specialist services provided. Based on the Plan contract, however, you cannot be asked to pay more than a $35 copayment for services obtained from a specialist. Therefore, we decided that the Plan has to adjust the copayment for the office visit (99213), tangential biopsy of skin (11102), and the destruction of pre-malignant lesions (17000, 17003) provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that this care is medically necessary. The Plan denied your request. The Plan says coverage criteria for the inpatient hospital stay are not met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 79-year-old female with right shoulder and acromioclavicular joint osteoarthritis. Past medical history is significant for hypertension and hyperlipidemia. The request is for an inpatient stay following the approved elective surgery. The review has determined that the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections (J7325).
You asked the Plan to pre-approve Synvisc. You say that Synvisc is medically necessary. The Plan denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered.
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 Synvisc. Our reviewer says that Synvisc is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drugs or any reason why the plan preferred drugs would be unsafe or ineffective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections (J7325).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an interdisciplinary team approach to rehab care.
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 physician reviewer found that you were admitted to the acute care hospital for weakness. You had an anterior cervical decompression surgery. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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.